UNIVERSITY  of  CALIFORNIA 


,:\  I 

LOS  AiNGELES 
LIBRARY 


PLATE   I 


I'YouKNCK  NIGHTINGALE 

Established  the  first  training-school  for  nurses,  i860. 


MODERN  METHODS 


IN 


NURSING 


BY 

GEORGIANA  J.  SANDERS 

FORMKRLY      ASSISTANT     MATRON      AT     ADUENBROOKES'      HOSPITAL, 

CAMBRIDGE,     ENGLAND;      FORMERLY     SUPERINTENDENT    OF     NURSES 

AT     THE      I'OLYCLINIC      HOSPITAL,      PHILADELPHIA,     AND     AT     THB 

MASSACHUSETTS     GENERAL      HOSPITAL,      BOSTON 


WITH    228     ILLUSTRATIONS 


"The  knowledge  that  will  hold  good 
in    working  —  cleave   thou    to    that." 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS   COMPANY 

1915 

STC.A1 


Published  February,  1912.    Reprinted  September,  1912,  August,  1013, 
March,  1914,  October,  1914,  and  January,  1915 


Copyright,  1912,  by  W.  B.  Saunders  Company 


Reprinted  September,  1915 


PRINTED     IN    AMERICA 


PRESS    OF 

W.    B.    SAUNDERS    COMPANY 
PHILADELPHIA 


TO 

W.    R.    S. 


PREFACE 


IN  preparing  a  text-book  that  shall  fit  the  curriculum 
required  by  a  modern  training-school,  one  has  to  face  the 
drawback  that  some  of  the  subjects  which  must  be  pre- 
sented can  be  but  very  superficially  appreciated  by  the 
writer.  Properly  speaking,  such  subjects  as  bacteriology, 
or  materia  medica,  presented  in  however  elementary  a 
form,  should  be  treated  by  those  whose  special  study  of 
the  subjects  qualifies  them  to  speak  with  authority,  a 
vantage  ground  which  we  as  nurses  are,  obviously,  far 
from  claiming.  The  same  is  true  of  such  matters  as  de- 
scriptions of  symptoms  and  suggestions  of  remedies. 

At  the  same  time,  those  of  us  who  have  been  for  many 
years  engaged  in  adapting  such  knowledge  to  the  require- 
ments of  nursing,  realize  that  it  is  often  as  important  to 
have  an  interpreter  as  to  have  exact  scientific  information 
on  these  subjects.  As  such  an  interpretation  the  chapters 
on  elementary  bacteriology  and  theories  of  immunity  are 
specially  presented,  leading  as  they  do  to  the  principles 
governing  all  our  modern  methods  of  nursing,  and  deter- 
mining in  particular  all  the  details  of  surgical  technic. 

In  writing  the  chapters  I  am  indebted  to  many  excellent 
lectures  given  in  one  or  other  training-school  with  which 
I  have  been  connected,  while  for  the  practical  and  tech- 
nical details  involved  I  have  gone  as  carefully  as  I  could 
into  those  adopted  by  the  leading  hospitals  in  America,  as 
well  as  those  with  which  my  own  wrork  has  made  me 
familiar,  especially  the  Polyclinic  Hospital,  Philadelphia, 
and  the  Massachusetts  General  Hospital,  Boston.  On 
this  point  my  thanks  are  specially  due  to  the  Johns  Hop- 
kins Hospital,  Baltimore,  the  Pennsylvania  Hospital, 
Philadelphia,  and  the  Philadelphia  Hospital.  Where  I 
have  used  a  text-book  I  have,  for  the  sake  of  simplicity, 
kept  to  the  one  with  which  I  was  most  familiar  in  teaching, 
H.  U.  Williams'  Manual  of  Bacteriology. 

5 


b  PREFACE 

In  the  chapters  on  food  and  food  values  I  have,  for  the 
same  reason,  used  chiefly  Miss  Farmer's  well-known  book 
on  invalid  cookery.  The  chapter  on  dieting  is  compiled 
chiefly  from  the  dietaries  in  use  in  various  hospitals,  es- 
pecially the  Polyclinic  Hospital,  Philadelphia,  and  the 
Massachusetts  General  Hospital,  Boston. 

Other  text-books  that  have  been  used  are  Dock's  Materia 
Medica  for  Nurses,  the  various  text-books  on  nursing,  and 
A.  A.  Stevens'  Manual  of  the  Practice  of  Medicine.  A 
great  deal  of  matter  used  has,  however,  been  so  long  in 
my  own  note-books  that,  gathered  originally  merely  for 
practical  purposes,  the  source  has  been  lost  sight  of,  and 
I  have  made  use  of  it  not  without  some  misgiving  that,  in 
so  doing,  I  may  prove  myself  an  unwilling  and  unconscious 
plagiarist. 

My  thanks  are  also  due  to  members  of  the  nursing  staff 
of  the  Massachusetts  General  Hospital,  the  Children's 
Hospital,  Boston,  and  the  Johns  Hopkins  Hospital  for 
the  charts  reproduced;  and  to  the  authorities  of  the 
Polyclinic  Hospital,  Philadelphia,  for  permission  to  make 
many  of  the  illustrations  in  their  wards. 

GEORGIANA  J.  SANDERS. 


CONTENTS 


PAGE 

INTRODUCTION 11 

The  Choice  of  a  Training-school,  11 — Qualifications  of  a 
Nurse,  30 — Commercial  Valuation,  38 — The  School  Course, 
44. 

CHAPTER  I 

PRACTICAL  METHODS 59 

Beds  and  Bed-making,  59. 

CHAPTER  II 
BATHS  AND  PACKS 92 

CHAPTER   III 

LOCAL  APPLICATIONS 119 

Inflammation,  119 — Application  of  Cold,  123 — Hot 
Applications,  128 — Hot  Compresses,  140 — Counterirri- 
tants,  140 — Rubefacients,  140— -Vesicants,  149 — Eschar- 
otics,  152— Liniments,  152 — Plasters,  153. 

CHAPTER  IV 

ENEMATA,    ENTEROCLYSIS.    CONTINUOUS    RECTAL    INFUSION, 
SUPPOSITORIES,    DOUCHES,   TAMPONS,    CATHETERIZA- 

TION,  LAVAGE,  GAVAGE,  NASAL  FEEDING 155 

Enemata,  155 — Enteroclysis,  167 — Continuous  Rectal 
Infusion  or  Seepage,  170 — Suppositories,  171 — Douches, 
172 — Tampons,  180 — Catheterizatidn,  182 — Lavage,  188 — 
Gavage,  192— Nasal  Feeding,  192. 

CHAPTER  V 

TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 194 

Temperature,  194— Pulse,  202— Respiration,  209— 
Charts,  216. 

CHAPTER  VI 

OBSERVATION  AND  EXAMINATION 219 

Symptoms,  219 — Physical  Signs,  223 — Examination  of 
Special  Organs,  229 — Examination  of  Organs  of  Special 
Sense,  239 — Observation  of  the  Skin,  244 — Examination  of 
the  Blood,  248— History-taking,  254. 

7 


8  CONTENTS 

CHAPTER  VII  PAGE 

EXAMINATION  OF  VOMITUS,  SPUTUM,  AND  EXCRETA 256 

The  Vomitus,  256— The  Sputum,  260— The  Feces,  264— 
The  Urine,  269— Examination  of  the  Urine,  274 — Ehrlich's 
Diazo-reaction,  284. 

CHAPTER  VIII 

BANDAGES  AND  SPLINTS 286 

Bandages,  286 — Plaster-of-Paris  Bandage,  304 — Splints, 
308 — Extension,  318 — Fracture  Boards,  Sand-bags,  Cra- 
dles, 322— Strapping,  323— Knots,  327. 

CHAPTER  IX 

MEDICINES 330 

Weights  and  Measures,  330 — The  Metric  System,  334 — 
Names  of  Preparations,  338 — Dosage,  342 — Time  of  Ad- 
ministration of  Drugs,  345 — Relative  Values  of  Different 
Forms  of  Preparations,  346 — Abbreviations,  347 — Familiar 
Preparations,  349 — Administration  of  Drugs,  350 — Hy- 
podermic Injection,  354 — Inhalation — Anesthesia,  358 — 
Inunction,  368. 

CHAPTER  X 

POISONS  AND  THEIR  ANTIDOTES 369 

Corrosive  Poisons,  372 — Irritant  Poisons,  375 — The 
Functional  Poisons,  381. 

CHAPTER  XI 

ELEMENTARY  BACTERIOLOGY  AND  THEORIES  OF  IMMUNITY  .  . .  387 

Classification,  387 — Bacteria,  389 — Protozoa,  394 — 
Cestodes — Nematodes,  395 — Examination  of  Bacteria,  396 
— Preparation  of  Specimens  for  Examination,  398 — -Cul- 
ture of  Bacteria,  402 — Infection,  407 — Modes  of  Trans- 
mission, 412 — Prophylaxis  of  the  Infectious  Diseases,  417 — 
Immunity,  421 — Action  of  Pathogenic  Bacteria,  431 — 
Nursing  in  Infectious  Diseases,  433. 

CHAPTER  XII 

SURGICAL  BACTERIOLOGY,  ASEPSIS 439 

Micro-organisms  Met  with  in  Surgery,  439 — Wound 
Infection;  440y-Antisepsis  and  Asepsis,  443 — Sterilization, 
447 — Antiseptics  in  General  Use,  454 — Disinfecting  a 
Room,  464— Disinfection  of  Excreta,  466 — Measuring 
Solutions,  469. 

CHAPTER  XIII 

PREPARATION  AND  STERILIZATION  IN  SURGICAL  WORK 471 

The  Hands,  471— The  Field  of  Operation,  473— Instru- 
ments, 478 — Rubber,  483 — Glass,  China,  and  Enamelware, 


CONTENTS  9 

PAGE 

487 — Sutures  and  Ligatures,  487 — Dusting-powders,  49.5 — 
Oils  and  Ointments,  496 — Solutions,  496 — Dressings,  496 — 
Sea-sponges,  499 — Hand-brushes  and  Nail-cleaners,  500 — 
Cultures,  500. 

CHAPTER  XIV 

SURGICAL  TECHNIC  AND  MINOR  SURGICAL  EVENTS 501 

Principles  of  Technic,  501 — Preparation  of  the  Skin,  508 
— Dressings,  509 — Hypodermoclysis  or  Subcutaneous  In- 
fusion, 514 — Intravenous  Infusion,  519 — Venesection; 
Phlebotomy,  521 — Injection  of  Antitoxin  Serums,  521— 
Minor  Surgical  Procedures,  522 — Exploration,  523 — Lum- 
bar Puncture,  524 — Blood  Culture,  527 — Paracentesis,  or 
Tapping,  528 — Aspiration,  530. 

CHAPTER  XV 

THE  OPERATING-ROOM 537 

Equipment  of  the  Operating-room,  537 — Duties  of  the 
Nurses,  547 — Operations  in  the  Patient's  Home,  555. 

CHAPTER  XVI 

THE  CARE  OF  OPERATION  CASES 565 

Preparation  of  the  Patient,  565 — Etherization,  568 — 
Immediate  Care  After  the  Operation,  570 — Abdominal 
Section  or  Laparotomy,  575 — Eye  Operations,  584 — 
Tracheotomy,  586 — Intubation,  589. 

CHAPTER  XVII 

NURSING  IN  ACCIDENTS  AND  EMERGENCIES 592 

Shock,  592— Hemorrhage,  594 — Treatment  of  Hemor- 
rhage, 596 — Special  Forms  of  Hemorrhage,  612 — Perfora- 
tion, 624. 

CHAPTER  XVIII 

NURSING  IN  ACCIDENTS  AND  EMERGENCIES  (Continued) 626 

Fractures,  626 — Treatment  of  Fractures,  631 — Disloca- 
tion or  Luxation,  645 — Wounds,  648 — Treatment  of 
Accidental  Wounds,  650 — Repair  of  the  Wound,  652 — 
Complications  of  Wounds,  655 — General  Infections  De- 
veloping from  Wounds,  660. 

CHAPTER  XIX 

NURSING  IN  ACCIDENTS  AND  EMERGENCIES  (Continued) 662 

Burns  and  Scalds,  662— Bites  and  Stings,  671— Frost- 
bite and  Exposure,  673 — Boils,  Styes,  Carbuncles,  Whit- 
low, 674 — Convulsions,  677 — Removal  of  Foreign  Bodies, 
685 — Artificial  Respiration,  690 — Fainting  or  Syncope,  696 
— Cerebral  Concussion,  Heat-stroke,  Starvation,  697. 


10  CONTENTS 

CHAPTER  XX  ,AGB 

SYMPTOMS  AND  CONDITIONS  FREQUENTLY  MET  WITH 701 

Pain,  701 — Delirium,  703 — Delusion,  Illusion,  Hallu- 
cination, 704 — Coma,  705 — Insomnia,  706 — Paralysis,  709 
— Edema,  711 — Vomiting  or  Emesis,  712 — Hiccup;  Singul- 
tus,  715 — Constipation,  716 — Diarrhea,  717 — Rigor,  719 — 
Sweating,  720— Fever,  722— Eruptive  Fevers,  727— Other 
Skin  Eruptions,  730. 

CHAPTER  XXI 

FOOD 737 

Chemical  Composition  of  Food,  738 — Caloric  Value  of 
Food,  746 — Digestibility  of  Food,  751 — Absorption  of 
Food,  755. 

CHAPTER  XXII 

THE  PREPARATION  OF  FOOD 758 

Proteins,  760 — Carbohydrates,  760 — Fats,  761 — Milk, 
762— Milk  as  a  Food  for  Infants,  768— Eggs,  775— Gruels, 
776 — Meat  Broths  and  Extracts,  777 — Water,  778 — 
Beverages,  779. 

CHAPTER  XXIII 

DIETS  AND  DIETING 782 

General  Division  of  Diets,  782 — Some  General  Points, 
786 — Diet  in  Special  Diseases,  787. 

CHAPTER  XXIV 

THE  HEAD  NURSE  AND  WARD  MANAGEMENT 805 

Division  of  Labor,  806— The  Orderly,  809— The  Ward- 
maid,  809— Hours  Off  Duty,  811— Reporting,  812— Stock- 
books  and  Inventories,  816 — Care  of  Linen,  820 — Blankets, 
822— Patient's  Effects,  823— Special  Duties  of  a  Head 
Nurse,  824 — The  Patient's  Visitors,  826 — Domestic  Work, 
827— Ventilation  and  Temperature,  837 — The  Visiting 
Rounds,  838. 

APPENDIX 

RECIPES 840 

Milk,  840— Eggs,  842— Gruels,  843— Meat-teas,  etc., 
844 — Beverages,  845. 

INDEX  . .  847 


MODERN  METHODS  IN  NURSING 


INTRODUCTION 

The  Choice  of  a  Training-school — The  Qualifications  of  a  Nurse — 
Her  Economic  Position — The  School  Course. 

THE    CHOICE   OF  A  TRAINING-SCHOOL 

ON  the  choice  of  her  training-school  depends,  to  a  large 
extent,  the  future  success  of  the  work  the  young  nurse 
has  chosen.  In  choosing,  however,  she  is  greatly  hampered 
by  difficulty  in  getting  reliable  advice  or  obtaining  ac- 
curate information.  As  a  consequence,  her  choice  is 
often  governed  by  circumstances  altogether  beside  the 
question,  such  as  the  wish  to  be  not  far  from  home,  to 
be  in  touch  with  a  special  circle  of  friends,  or  to  live  in 
some  part  of  the  land  that  she  considers  more  progressive 
and  interesting  than  her  home  surroundings.  Probably 
the  next  important  point  to  help  in  her  decision  is  the 
length  of  the  training — the  shorter  the  training,  she 
naturally  concludes,  the  sooner  will  she  be  earning  for 
herself,  and  usually  she  tries  to  find  a  school  where  no 
"menial  work  "  is  expected  of  the  pupils.  Her  ignorance 
of  the  work  she  undertakes  prevents  her  seeking  infor- 
mation on  such  points  as  the  methods  of  teaching  pursued, 
the  subjects  taught,  and  the  variety  of  work  which,  from 
the  kind  of  patients  admitted  to  the  hospital,  she  may 
expect  to  see.  For  her  choice  a  large  variety  of  training- 
schools  offer  themselves. 

First,  and  most  specious  in  argument,  are  the  correspond- 
ence schools  and  the  so-called  short-course  schools.  They 
profess,  by  theoretic  teaching  almost  entirely,  to  teach  in 
a  few  weeks  all  a  nurse  need  know.  She  is  taught  to 
count  a  normal  pulse,  and  to  make  herself  acquainted 

11 


12  INTRODUCTION 

with  the  many  variations  from  the  normal  caused  by 
disease,  without  an  opportunity  of  observing  an  abnormal 
pulse;  she  is  taught  to  control  hemorrhage  without  seeing 
blood,  to  prepare  for  an  operation  by  looking  on  two  or 
three  times  at  an  operation  in  a  public  clinic. 

The  amateur  may  receive  some  interesting  information 
from  such  teaching,  though  not  of  the  kind  that  will 
"  hold  good  in  working."  For  the  nurse  who  wishes  to 
be  successful  in  her  calling,  two  simple  qualifications  are 
undeniably  necessary :  from  the  point  of  view  of  the  patient, 
deftness  and  skill;  from  that  of  the  doctor,  the  power  of 
accurate  observation.  These  cannot  be  replaced  by 
theoretic  knowledge  or  scientific  information,  and  can 
be  acquired  only  at  the  patient's  bedside,  and  by  long 
practice  and  experience. 

To  expect  to  "  learn  nursing"  under  the  instruction  of 
the  correspondence  or  short-course  schools  is  as  common- 
sensible  as  to  expect  to  acquire  a  practical  knowledge  of 
gardening  by  studying  the  subject  in  a  city  garret,  or  to 
attempt  to  learn  to  swim  without  ever  being  in  the  water. 

Secondly,  we  may  take  the  training-schools  attached 
to  special  hospitals — hospitals  that  treat  either  one  dis- 
ease, one  sex,  or  one  age.  Under  the  first  heading  we 
find  the  infectious  hospitals,  sanatoria  for  tuberculosis, 
hospitals  for  the  treatment  of  cancer,  of  nervous  diseases, 
orthopedic  hospitals,  eye  and  ear  hospitals,  the  insane 
asylums,  and  hospitals  devoted  to  special  research. 

Hospitals  for  women  only  may  be  general  hospitals 
(see  below),  or  treat  only  one  variety  of  case,  as  in  the 
case  of  the  hospitals  devoted  entirely  to  maternity  or  to 
gynecologic  work.  (Hospitals  for  special  diseases  of 
men  exist,  but  are  obviously  not  of  account  as  training- 
schools  for  women  nurses.) 

Hospitals  for  children  frequently  treat  most  of  the  dis- 
eases found  in  a  general  hospital.  In  children,  however, 
disease  has  many  special  manifestations  and  may  differ 
greatly  from  the  same  disease  in  an  adult.  The  age  limit 
also  excludes  a  large  field  of  modern  surgery,  and  all 
accidents  and  emergencies  except  those  to  which  children 
are  liable,  such  as  burns,  scalds,  and  fractures. 


THE   CHOICE   OF  A  TRAINING-SCHOOL  13 

In  view  of  the  excellent  training-schools  connected 
with  the  best  of  the  general  hospitals  for  women,  it  is 
misleading  to  class  them,  in  examining  their  limitations, 
with  the  hospitals  devoted  to  special  diseases.  Fre- 
quently such  a  hospital  is  a  medical  school  of  the  first 
order,  and  the  pupil  nurses  receive  theoretic  teaching 
and  practical  experience  in  every  part  of  their  work, 
similar,  except  in  two  details,  to  that  given  their  sister 
workers  in  the  general  hospital.  There  is,  however,  no 
experience  in  nursing  men,  and  only  very  limited  experi- 
ence in  accident  and  emergency  work.  Usually  the  women's 
hospital  includes  the  care  of  children. 

It  is  open,  however,  to  all  general  hospitals  for  women 
to  overcome  their  limitations  on  these  points,  by  procuring 
for  their  pupil  nurses  admission  during  part  of  their  train- 
ing to  the  men's  wards  and  accident  department  of  a  gen- 
eral hospital.  Where  this  is  done,  the  pupils  work  under 
no  real  disadvantage,  and  the  training-school  may  stand 
or  fall  on  its  own  merits. 

Of  the  strictly  special  hospitals  this  is  not  the  case, 
and  the  pupil  electing  to  train  in  one  of  them  should 
do  so  with  her  eyes  open,  and  understand  that  although 
she  may  receive  a  diploma  which  shall  entitle  her  to  the 
name  of  trained  nurse,  she  is  trained  only  in  one  branch 
of  nursing,  and  should  honestly  continue  to  nurse  only 
just  that  variety  of  case  and  no  other.  A  maternity 
nurse  has  no  special  knowledge  to  guide  her  in  nursing  a 
case  of  typhoid  fever;  a  woman  trained  only  in  nervous 
work  has  no  moral  right  to  take  a  maternity  case. 

The  inducements  usually  used  by  such  hospitals  toward^ 
candidates  for  admission  to  their  training-schools  are— a 
shorter  course,  somewhat  higher  salaries,  a  lower  educational 
standard  necessary  for  admission,  entrance  at  an  earlier 
age,  and,  very  frequently,  absence  of  "  menial  "  or  domestic 
work.  Usually  the  applicant  is  assured  that  the  demand 
for  nursing  in  this  special  branch  is  so  great  that  she  can 
be  sure  of  constant  employment  when  her  training  is  over. 
Should  she,  on  finishing,  feel  that  her  training  is  one-sided, 
she  can,  she  is  told,  always  take  a  post-graduate  course  in 
a  general  hospital,  and  so  make  up  for  any  shortcomings. 


14  INTRODUCTION 

Emphatically,  one  would  advise  young  nurses  to  begin 
with  the  root  and  leave  the  branches  for  a  later  date. 
A  doctor  specializes  only  after  he  has  been  thoroughly 
grounded  in  all  branches  of  his  work;  he  could  not  other- 
wise obtain  a  degree.  At  the  end  of  a  special  training  a 
very  large  number  of  nurses  find  themselves  dissatisfied 
with  the  narrow  scope  of  their  knowledge,  and  feel  that 
they  have  spent  the  years  of  their  training  with  more 
profit  to  the  hospital  than  to  themselves.  They  realize, 
in  fact,  that  they  are  just  half-trained. 

They  turn  as  a  refuge  to  the  post-graduate  courses 
offered  by  some  general  hospitals,  to  find  that  very  few 
hospitals  give  them  at  all,  and,  in  almost  all  cases,  only 
to  graduates  from  a  general  hospital.  If  a  nurse  has  the 
means,  she  may  begin  again  in  a  general  hospital  and 
train 'for  three  more  years,  and  that  women  not  infrequently 
do  so  is  an  emphatic  proof  of  the  undesirability  of  a  train- 
ing on  special  lines  only.  The  majority  have  neither  time 
nor  money  to  give  to  a  second  training,  and  accept  their 
limited  career,  usually  with  openly  expressed  regret  that 
they  had  not  understood  more  fully  the  condition  of  train- 
ing when  they  began. 

Much  of  the  material  for  training  in  the  special  hospitals 
is  of  unusual  value,  especially,  perhaps,  in  the  maternity 
hospitals,  the  eye  hospitals,  and  the  hospitals  for  ner- 
vous diseases,  the  latter  with  their  special  instruction 
in  massage,  hydrotherapeutics,  and  allied  subjects. 
Affiliated  with  the  smaller  general  hospitals,  which  are 
often  deficient  in  variety  of  work,  they  would  fulfil  an 
important  place  in  the  training  of  nurses. 

Children's  hospitals  furnish  a  peculiarly  valuable 
training  in  many  ways,  but  share  the  limitations  of  the 
other  special  hospitals  in  that  at  the  end  of  the  training 
the  graduate  is  less  completely  equipped  than  if  she  had 
spent  the  same  amount  of  time  in  a  general  hospital,  and 
with  no  harder  work.  Several  children's  hospitals  recog- 
nize this  and  provide  for  their  pupils  a  year's  work  and 
instruction  in  a  general  hospital,  at  the  close  of  two  years' 
training  in  the  children's  hospital.  Special  attention 
is  then  paid  to  those  branches  in  which  children's  training 


THE    CHOICE   OF   A   TRAINING-SCHOOL  15 

is  deficient,  such  as  gynecology,  major  surgery  generally, 
and  accident  and  emergency  work.  Where  this  is  done, 
the  training  is  frequently  excellent  and  has  the  advantage 
that,  owing  to  less  physical  strain  and  other  obvious  con- 
ditions, it  is  practical  to  take  the  pupils  at  least  two  years 
earlier  than  in  a  general  hospital. 

The  next  group  of  hospitals  to  consider,  and  the  most 
important  from  the  point  of  view  of  the  pupil  nurse,  are 
the  general  hospitals. 

The  term  general  hospital  is  used  broadly  for  those 
hospitals  that  treat  all  diseases,  in  contradistinction  to 
those  for  one  variety  of  disease.  The  point,  however,  is 
often  debated,  and  especially  in  relation  to  the  teaching 
given  by  a  hospital.  It  is  maintained  that  the  terms 
"  general  hospital  for  women,"  "  general  hospital  for 
children,"  are  paradoxic,  and  that  such  hospitals  should 
be  classed  as  special  hospitals,  in  recognition  of  their 
limitations.  It  is,  however,  difficult  to  arrive  at  any 
other  designation  that  would  distinguish  them  in  the 
first  instance  from  the  women's  hospitals  treating  only 
diseases  peculiar  to  women,  and  in  the  second  instance 
from  those  devoted  to  special  departments  of  children's 
diseases,  such  as  the  disorders  of  infancy  or  orthopedics. 

In  the  strictest  sense,  however,  it  is  considered  that  the 
general  hospital  must  treat  all  medical  diseases,  except 
contagious  diseases,  and  all  surgical  diseases,  including 
the  special  surgical  departments  of  gynecology,  ortho- 
pedics, and  surgery  of  the  eye,  ear,  nose,  and  throat,  and 
that  they  shall  receive  both  sexes  and  all  ages,  though,  as 
a  matter  of  fact,  infants  under  two  years  of  age  are  often 
excluded. 

Contagious  diseases  are,  at  the  present  day,  generally 
treated  in  buildings  devoted  entirely  to  their  use,  their 
presence  in  a  general  hospital  being  attended  with  prac- 
tical difficulties  of  administration,  and  some  danger  to 
the  other  inmates.  A  maternity  department  is  frequently 
found  in  a  general  hospital.  In  olden  times  the  hospitals 
were  also  the  almshouses,  the  orphanages,  and  the  asy- 
lums, and  the  maternity  department  was  part  of  the  hospi- 
tal as  a  matter  of  course,  birth  being  classed  as  a  variety 


16  INTRODUCTION 

of  disease.  With  the  growth  of  more  definite  knowledge 
on  the  subject  of  contagion  in  the  middle  of  the  last  cen- 
tury, it  was  concluded  that  the  prevalence  of  puerperal 
fever,  common  at  the  time  in  the  maternity  wards  of  the 
general  hospital,  was  due  to  direct  infection  from  the  other 
wards,  especially  from  the  surgical  wards,  and  from  the 
postmortem  and  dissecting-rooms,  carried  by  the  students 
and  doctors.  Antiseptic  treatment  was  then  unknown; 
common  humanity  and  the  pressure  of  public  opinion  de- 
manded that  maternity  cases  should  not  be  treated  in  gen- 
eral hospitals,  and  separate  buildings,  with  special  endow- 
ments, replaced  in  most  instances  the  maternity  wards. 
The  hospitals,  however,  continued  to  be  general  hospitals, 
as  were  similar  institutions  established  later  without  a 
maternity  department. 

With  modern  asepsis,  and  enlightened  ideas  on  the 
prevention  of  infection,  the  maternity  cases  have  been 
once  more  admitted  to  many  general  hospitals,  an  isolated 
wing  being  in  all  cases  provided.  In  most  instances 
these  hospitals  are  teaching  schools,  the  advantage  of  the 
maternity  department  being  the  convenience  to  doctor 
and  student  in  having  all  available  branches  of  their  work 
under  one  roof. 

Many  hospitals,  both  large  and  small,  especially  those 
not  connected  with  a  teaching  school,  have,  however, 
considered  the  conditions  of  a  general  hospital  as  involving 
a  menace  to  the  maternity  department,  and  refuse  to 
have  one.  None  the  less  they  are  classed  as  general 
hospitals — it  would  be  impractical  to  designate  them 
otherwise. 

In  a  nurse's  training,  however,  maternity  training  should 
be  insisted  upon,  in  so  many  instances  after  her  graduation 
is  the  care  of  such  cases  unavoidably  thrown  upon  her. 
The  majority  of  training-schools,  if  they  have  no  such 
department  in  their  own  hospital,  arrange  either  with  a 
special  maternity  hospital  or  with  another  hospital  having 
a  maternity  department,  to  receive  their  pupils  for  train- 
ing for  a  limited  length  of  time. 

Before  choosing  her  school  the  applicant  should  inform 
herself  on  this  point.  If,  for  definite  reasons,  she  chooses 


THE    CHOICE   OF   A  TRAINING-SCHOOL  17 

a  school  that  gives  no  experience  in  maternity  work,  she 
should  make  it  a  subject  for  early  postgraduate  work. 

The  general  hospitals  may  be  subdivided  into  the 
private  hospitals,  the  small  general  hospitals,  hospitals 
for  private  patients  only,  the  large  general  hospitals 
not  connected  with  a  teaching-school,  and  those,  both 
large  and  small,  that  are  connected  with  the  medical 
school  of  a  college  or  university. 

The  term  private  hospital  signifies  that  the  hospital 
is  the  venture  of  a  private  individual  who  receives  the 
fees  of  the  patients  and  administers  its  finances,  and  is 
not  governed  by  a  public  board,  with  its  affairs  open  to 
public  inspection  and  criticism.  A  number  of  private 
hospitals  have  no  training-school;  they  are  nursed  by 
graduate  nurses  entirely  and  frequently  make  a  valuable 
field  for  postgraduate  experience;  generally  the  work  in 
them  is  more  or  less  specialized.  A  great  many  are, 
however,  first  and  last,  a  financial  speculation,  the  train- 
ing-school existing  because  untrained  nursing  is  cheaper 
than  graduate  nursing.  In  some,  little  attempt  is  made  to 
teach  the  nurses,  and  little  is  spent  on  their  comfort  or 
welfare.  The  work  is  generally  limited  in  variety,  and 
with  no  adequate  instruction  to  make  the  most  of  what 
exists,  pupils  are  graduated  and  turned  out  as  private 
nurses,  half-trained  and  ignorant,  and  not  able  to  compete 
with  their  more  thoroughly  trained  sisters.  The  full 
limitation  of  such  training  is  realized  by  nurses  in  those 
States  which  have  State  registration,  when  they  discover 
that  they  are  unable  to  enroll  themselves  as  registered 
nurses  unless  their  training  comes  up  to  definite  standards 
of  work  and  instruction. 

The  inducements  usually  offered  by  such  training- 
schools  are  admission  at  an  early  age,  lighter  work  (a 
misleading  promise,  as  the  number  of  workers  is  generally 
small),  and  a  shorter  course. 

Under  the  heading  of  public  general  hospitals  we  find 
a  large  variety  of  institutions,  from  the  small  local  hospital 
in  country  districts,  containing  from  10  to  50  beds,  to 
the  large  institutions  of  the  busy  city. 

Provided  the  service  is  sufficiently  active  to  give  enough 
2 


18  INTRODUCTION 

variety  of  work,  and  that  accident  and  emergency  casea 
arc  received,  the  small  hospitals  may,  in  good  hands, 
become  a  useful  field  for  training  nurses.  These  two 
conditions  frequently,  however,  do  not  exist.  In  investi- 
gating the  conditions  of  training,  it  should  be  ascertained 
whether  or  not  the  superintendent  of  nurses  is  herself  a 
graduate  nurse,  and  a  graduate  of  a  reputable  school,  and  if 
the  pupils  are  under  her  care.  Frequently  it  will  be  found 
that  the  pupils  are  directly  under  the  male  superintendent 
of  the  hospital  (usually  a  young  doctor),  the  superin- 
tendent of  nurses  being  practically  his  assistant.  In 
hospitals  so  governed  the  training  of  the  nurses  is  probably 
not  of  a  high  order.  The  candidate  should  also  inform 
herself  of  the  amount  and  quality  of  instruction  she  may 
expect  to  receive  (see  below),  and  if  it  satisfies  the  require- 
ments for  registration. 

In  the  hands  of  an  able  superintendent  of  nurses  the 
small  general  hospital  in  a  country  district  is  frequently 
productive  of  excellent  training,  and  thorough,  if  not 
advanced,  instruction.  Women  of  slight  physique  may 
frequently,  with  advantage,  enter  such  training-schools, 
instead  of  risking  the  more  strenuous  work  of  a  city  hos- 
pital. The  hours  are  generally  longer,  and  the  night  duty 
more  frequent,  but  the  average  work  is  much  lighter, 
and  the  rush  of  acute  work,  operations,  and  so  forth,  not 
nearly  so  great.  As  a  rule,  graduates  of  the  small  schools 
are  successful  as  private  nurses,  but  are  apt  to  be  over- 
whelmed by  an  active  hospital  life.  When  the  small  school 
is  of  good  standing,  its  graduate  pupils  are  eligible  for 
postgraduate  work  in  the  hospitals  that  give  such  a  course. 

The  large  general  hospitals,  as  already  said,  are  divided 
into  two  classes — those  connected  with  a  college  or  med- 
ical school,  and  those  that  have  no  such  connection. 
Either  has  some  advantage  over  the  other  considered  from 
the  point  of  view  of  the  training-school,  but  the  fact  of 
the  connection  with  the  teaching  school  makes  less  differ- 
ence than  might  be  supposed.  In  college  or  university 
hospitals  the  work  is  generally  more  varied  and  more 
acute,  convalescent  patients  are  hurried  out  to  make 
room  for  fresh  cases,  new  methods  and  experimental 


THE   CHOICE   OF   A   TRAINING-SCHOOL  19 

treatment  are  usually  practised  sooner  than  in  other 
hospitals.  In  the  hospitals  without  these  conditions 
it  is,  however,  often  possible  to  spend  more  time  over  the 
individual  case,  and  the  work  expected  from  the  nurses 
may  frequently  be  found  to  be  more  finished,  if  less 
varied. 

The  success  of  a  training-school  is,  in  effect,  independ- 
ent of  this  consideration. 

Having  thus  briefly  enumerated  the  variety  of  train- 
ing-school the  candidate  may  have  to  choose  from,  it  is 
next  pertinent  to  put  before  her  some  of  the  essentials  of 
a  good  training,  and  some  of  the  points  on  which  she  may 
reasonably  inform  herself  in  connection  with  the  school 
to  which  she  contemplates  gaining  admission. 

The  chief  essentials  are  sound  instruction  and  sufficient 
material  to  learn  from.  Minor  points — minor  because 
they  cannot  take  the  place  of  either — are:  reasonable 
working  hours,  sufficient  vacation,  and  adequate  care  for 
her  comfort  and  well-being  during  her  training. 

If  a  woman  wishes  to  go  to  college,  she  informs  herself 
most  carefully  of  the  general  standing  of  the  different 
colleges,  the  quality  of  the  instruction,  and  the  value  of 
the  degree  each  college  may  give.  This  she  does  by  study- 
ing the  prospectuses  and  schedules  of  curriculum  they 
issue,  by  talking  over  the  subject  with  those  who  are 
well  informed,  and  frequently  by  a  personal  visit  to  one 
or  other  college.  Rarely,  it  would  seem,  does  a  woman 
take  anything  like  the  same  pains  in  selecting  a  training- 
school,  and  yet  from  the  existing  conditions  among 
hospitals  it  is  far  more  easy  to  choose  wrongly.  The 
methods  of  finding  out  about  either  are  identical. 

What  is  not  apparent,  however,  is  what  constitutes 
sufficient  material  or  adequate  instruction.  The  former 
is  the  least  simple  to  define.  A  hospital  of  100  beds 
with  an  acute  service  may  offer  more  scope  for  teach- 
ing than  a  hospital  of  1000  beds  where  a  large  per- 
centage of  the  cases  are  chronic  invalids  or  simply  pauper 
inmates.  There  may  be  the  same  number  or  even  a 
larger  number  of  acute  cases  treated  in  the  year  in  the 
latter  institution,  but  the  work  is  not  concentrated  on 


20  INTRODUCTION 

their  care,  and  much  of  the  pupil's  time  must  be  given 
to  work  from  which  she  does  not  acquire  much  variety 
of  experience.  Usually,  however,  she  is  safe  to  conclude 
that  if  a  general  hospital  is  situated  in  a  populous  part  of 
city  or  town,  and  if  its  published  reports  (which  are  al- 
ways available)  do  not  show  a  marked  discrepancy 
between  the  number  of  bed  patients  and  the  number  of 
acute  cases,  the  work  will  be  sufficiently  acute  and  varied 
for  the  experience  necessary  for  her  work. 

As  regards  the  question  of  hospital  facilities,  the  Board 
of  Regents  for  the  State  of  New  York  has  laid  down  the 
following  qualifications  for-  training-schools  seeking  regis- 
tration : 

"Hand-book  No,  13.  Relating  to  Higher  Education. 
Registration  of  Nurses,  Law,  Ordinances,  and  Regula- 
tions, July,  1906. 

11  Hospital  Facilities. — For  registration  a  nurse  train- 
ing-school must  be  connected  with  a  hospital  (or  sana- 
torium) having  not  less  than  twenty-five  beds,  and  the 
number  of  beds  must  be  from  two  to  four  times  the  number 
of  students  in  the  school,  depending  on  the  character  of 
the  hospital's  facilities  for  private  or  ward  practice." 

What  is  of  primary  importance,  however,  is  the  way 
in  which  this  material  is  made  of  practical  use  by  the 
methods  of  instruction  maintained,  and  on  this  point 
it  is  not  always  easy  to  obtain  definite  information. 
Twenty-five  cases  properly  nursed,  with  the  methods  em- 
ployed carefully  taught,  and  the  reasons  explained,  are 
more  valuable  to  the  pupil  than  a  hundred  cases  where 
the  nursing  is  indifferent,  and  the  pupils  are  left  to  pick  up 
their  work  for  themselves. 

Leaving  for  the  moment  the  methods  of  instruction  on 
one  side,  the  candidate  should  inform  herself  which  are 
the  subjects  in  which  she  should  receive  both  practical 
and  theoretic  instruction.  The  question  of  a  nurse's 
education  was,  until  recently,  a  matter  left  almost  entirely 
to  the  individual  school,  and  there  was  but  little  unity  of 
ideas  on  the  subject.  With  the  spread  of  registration  for 
nurses  in  the  different  States  it  became  necessary  to  fix 


THE    CHOICE    OF   A   TRAINING-SCHOOL  21 

definite  standards  by  which  a  nurse's  ability  to  pursue  her 
profession  could  be  tested.  As  a  consequence,  a  definite 
standard  of  instruction  to  fit  her  to  pass  these  tests  became 
also  necessary. 

No  board  has  gone  into  the  question  more  thoroughly 
than  the  State  Board  of  Regents  of  New  York.  In  hand- 
book No.  13,  from  which  we  have  already  quoted,  the 
following  standards  of  instruction  are  laid  down: 

"  Training-schools  for  nurses  registered  by  the  Regents 
shall  provide  both  practical  and  theoretic  instruction  in 
the  following  branches  of  nursing:  (a)  Medical  nursing 
(including  materia  medica);  (6)  surgical  nursing,  with 
operative  technic,  including  (c)  gynecologic,  (d)  obstet- 
ric nursing,  each  pupil  to  have  the  care  of  not  less  than 
six  cases,  (e)  children's  nursing,  (/)  a  thorough  course  of 
theoretic  instruction  in  contagious  nursing  where  prac- 
tical experience  is  impossible,  (0)  diet  cooking  for  the  sick, 
including — (1)  12  lessons  in  cooking  in  a  good  technical 
school,  or  with  a  competent  diet  teacher,  (2)  food  values 
and  feeding  in  special  cases  to  be  taught  in  classes,  not 
by  lectures,  (h)  bacteriology." 

One  subject  not  mentioned  in  the  above  list  is,  how- 
ever, required  in  the  full  examination  for  registration, 
elementary  anatomy  and  physiology,  and  should  form 
part  of  a  training-school  curriculum. 

The  above  constitutes  what  is  at  the  present  day  con- 
sidered as  the  minimum  requirement  of  a  nurse's  educa- 
tion: that  is  to  say,  with  less  than  the  above  a  nurse's 
education  is  not  complete. 

It  is  a  simple  matter  for  the  applicant  to  inform  herself 
whether  the  training-school  she  wishes  to  enter  is  prepared 
to  give  her  such  instruction,  and  capable  of  so  doing. 

In  the  State  of  New  York  such  schools  will  usually  be 
found  to  be  registered,  a  fact  which  in  itself  guarantees 
to  the  pupil  that  the  educational  requirements  of  the 
Regents  are  fulfilled.  In  other  States  the  principal 
schools  will  also  frequently  be  found  to  be  registered  by 
the  New  York  State  Board  of  Regents.  In  no  case,  how- 
ever, should  a  pupil  be  satisfied  with  less  than  the  above 
standard  requires.  The  legal  registration  of  nurses  is 


22  INTRODUCTION 

slowly  but  surely  spreading  through  the  different  States, 
and  should  a  nurse  desire  to  work  in  a  State  where  regis- 
tration exists,  she  will  find  herself  seriously  hampered  in 
her  career  if  her  training  does  not  come  up  to  registration 
requirements. 

Many  hospitals  give  a  much  larger  curriculum,  the 
principal  extra  subjects  taught  being  massage,  hydro- 
therapeutics,  dispensing,  practical  housekeeping,  element- 
ary laboratory  work,  special  courses  on  such  subjects  as 
treatment  of  diseases  of  the  eye  or  the  ear,  and  special 
instruction  in  social  service  work  and  allied  questions. 

An  applicant  may  hesitate  as  to  which  is  the  wisest, 
to  take  the  simplest  course  and  supplement  it  with  her 
own  reading,  or  to  enter  the  school  that  offers  the  widest 
opportunity  for  studying  her  profession.  Practical  reasons 
should  guide  her.  If  she  is  of  slight  physique,  if  she  has 
no  natural  facility  for  study,  if  her  education  has  been 
somewhat  deficient,  she  is  wise  not  to  attempt  more  than 
the  minimum  course,  the  practical  work  being  in  itself 
an  unavoidable  tax  on  her  strength.  In  the  case  of  a 
woman  trained  to  study  and  accustomed  to  exercising 
her  brains,  to  meeting  the  requirements  of  examinations, 
the  conditions  are  different.  By  taking  the  widest  edu- 
cation open  to  her  she  can  fit  herself  to  specialize  in  one 
or  other  branch,  of  the  special  interest  of  which  she  had 
no  conception  when  she  began  her  training.  The  train- 
ing-schools are  not  only  for  the  teaching  of  nursing  as 
generally  understood,  they  are  also  for  training  the  future 
instructors,  heads  of  departments,  and  superintendents 
of  nurses.  For  such  the  education  should  be  broad  and 
progressive.  A  nurse  may  not,  at  the  beginning  of  her 
career,  be  decided  as  to  the  branch  of  nursing  she  will 
take  up  after  her  training,  but  she  can  understand  that 
the  greater  will  always  include  the  less;  where  it  is  in  her 
power  to  take  the  best  it  is  usually  wisest  to  do  so. 

As  important  to  the  pupil  as  the  subject  matter  is  the 
method  of  instruction  employed,  a  point  on  which  it  is 
not  always  easy  to  get  practical  information. 

In  the  theoretic  teaching  methods  vary  from  the  em- 
ployment of  one  lecturer  who  teaches  each  subject  in 


THE    ('HOICK    OF    A    TRAINING-SCHOOL  23 

turn  ami  divides  the  teaching  year  between  the  various 
subjects,  to  the  separate  instructor  for  each  course,  with 
a  regularly  organized  system  of  class  work  in  conjunction 
with  the  lectures.  It  will  be  understood  that  the  first 
method  has,  even  in  capable  hands,  little  educational 
value,  except  in  so  far  as  it  may  direct  the  pupil's  reading. 
On  the  methods  of  theoretic  teaching  it  is,  however, 
simple  to  get  definite  information.  A  school  that  gives 
adequate  theoretic  instruction  usually  issues  a  schedule 
of  its  course,  and  if  not,  is  always  prepared  with  definite 
statements. 

On  practical  methods  of  instruction  it  is  more  difficult 
to  estimate  the  efficiency,  as  without  experience  it  is  not 
possible  to  weigh  the  advantages  of  the  different  systems. 

Two  methods  of  teaching  the  pupil  her  practical  work 
are  in  vogue  : 

The  first,  the  older  method,  is  that  of  starting  her  in  a 
ward,  with  the  minor  duties  of  a  ward  nurse,  the  fetching 
and  carrying,  care  of  convalescents,  bed-making,  baths,  and 
so  forth.  She  is  under  the  care  of  the  head  nurse  of  the 
ward,  who  teaches  her  the  different  details  of  her  work  step 
by  step,  largely  by  allowing  her  to  help  the  senior  pupils  in 
the  performance  of  their  various  duties. 

The  newer  method  is  to  place  the  pupils  in  classes  under 
one  instructor,  who  herself  teaches  them  in  the  wards  and 
in  the  class-room,  by  demonstration  and  careful  super- 
vision, the  practical  details  of  a  nurse's  work,  before  they 
are  admitted  into  the  wards  as  ordinary  pupil  nurses. 
In  different  hospitals  such  preliminary  instruction  is 
given  for  periods  of  different  lengths,  from  a  few  weeks 
to  the  entire  six  months  of  the  probationary  period. 

Either  system  may  be  said  to  have  some  advantages 
and  some  disadvantages.  For  the  former  it  is  claimed 
as  an  advantage  that  the  pupil  is  thrown  at  once  directly 
into  contact  with  the  patients,  and  has  the  opportunity 
of  showing  at  an  early  date  whether  she  is  possessed  of 
certain  temperamental  qualifications  for  her  calling,  such 
as  patience,  perseverance,  courage,  kindness,  observa- 
tion, tact,  and  so  forth.  Many  think,  too,  that  a  pupil 
develops  more  quickly  if  she  feels  herself  an  integral  part 


24  INTRODUCTION 

of  the  ward  in  which  she  is  placed,  and  responsible  for 
the  performance  of  some  duties,  however  minor.  The 
principal  disadvantage  is  that  the  teaching  is  usually  far 
from  thorough.  A  head  nurse  is  not  appointed  primarily 
because  she  is  a  good  teacher — the  best  may  altogether 
lack  the  qualification,  and  she  has,  besides,  numerous 
other  duties  equally  exacting  and  important.  Nor  is  it 
practical  for  her  to  have  one  pupil  always  under  her  eye. 
Consequently  the  pupil  is  frequently  left  to  pick  up  her 
work  from  watching  her  fellow-nurses,  or  to  get  along  with 
good-natured  instruction  from  an  older  pupil.  Undoubt- 
edly there  is  a  risk  that  she  may  attempt  duties  she  is 
not  skilled  to  perform,  or  have  responsibilities  thrown  on 
her  before  she  is  qualified  to  bear  them,  and  both  patients 
and  pupil  suffer. 

In  the  newer  method  the  pupil  is  under  an  instructor 
chosen  specially  for  her  ability  to  teach,  and  with  the 
teaching  of  the  pupils  as  her  most  important  duty.  Care 
is  taken  that  she  is  taught  the  best  methods  thoroughly, 
and  every  pupil's  work  is  under  the  closest  supervision. 
The  pupils  benefit  and  the  patient  runs  no  risk  of  unskil- 
ful handling.  If  the  method  has  a  disadvantage,  it  is 
the  subtle  one  of  placing  the  patient  in  the  light  of  so 
much  material  for  the  benefit  of  the  pupil,  than  which 
attitude  none  could  be  more  regrettable,  or  further  from 
the  ideals  of  our  profession. 

In  choosing  her  school  it  would  be  misleading  for  the 
candidate  to  base  her  choice  entirely  on  one  point.  When, 
however,  she  finds  a  school  that  does  give  preliminary 
instruction  to  its  probationers,  she  may  feel  assured  that 
the  importance  of  giving  her  thorough  teaching  is  realized, 
and  that  she  has  to  do  with  a  training-school  that  appre- 
ciates its  responsibilities  toward  its  pupils,  and  is  in  sym- 
pathy with  the  demands  of  modern  progress. 

The  remaining  points  for  the  consideration  of  a  would- 
be  pupil  are  the  length  of  course,  the  hours  of  work,  and 
the  question  of  salary.  On  these  points  she  must  be  guided 
by  averages,  and  their  consideration  should  always  be 
taken  in  conjunction  with  the  more  important  points  of 
quality  of  work  and  instruction. 


THE   CHOICE    OF   A   TRAINING-SCHOOL  25 

The  lowest  length  of  course  admitted  by  the  boards 
of  registration  is  two  years  in  a  hospital  of  the  above 
facilities,  giving  the  required  instruction.  This  is  again 
a  minimum  requirement.  The  average  course  is  three 
years,  and  the  longer  course  is  strongly  advocated  by 
such  influential  bodies  as  the  American  Society  of  Super- 
intendents of  Training-schools  for  Nurses  and  the  Associ- 
ated AlumnaB  of  the  American  Graduate  Nurses,  and  the 
Matron's  Council  of  Great  Britain.  It  is  maintained  that 
if  the  subjects  required  are  to  be  adequately  taught, 
two  years  is  not  sufficiently  long.  Either  the  teaching 
must  be  superficial,  or  undue  stress  is  laid  upon  the  pupil, 
to  her  disadvantage. 

On  one  point  the  applicant  should  be  clear,  that  the 
term  of  her  training  is  spent  in  the  hospital,  and  that  she 
is  not  used  in  the  capacity  of  a  private  nurse,  to  earn 
funds  for  the  hospital.  A  few  training-schools  consider 
that  a  nurse  should,  in  her  training,  have  a  limited  number 
of  private  cases  outside  the  hospital,  but  under  the  super- 
vision of  her  training-school,  as  a  test  of  her  capability 
of  undertaking  such  work  after  her  graduation.  While 
the  idea  is  in  itself  sound,  it  is  found  open  to  much  abuse : 
an  acceptable  nurse  is  liable  to  spend  an  undue  portion 
of  her  time  away  from  the  school,  while,  at  best,  close 
supervision  is  impractical.  If  the  method  is  practised 
for  the  above  reason,  the  length  of  time  so  spent  should  be 
strictly  limited. 

On  this  point  the  Board  of  Regents  expresses  itself  as 
follows  (Handbook  No.  13) : 

"  Training-schools  giving  a  three  years'  course  and 
wishing  to  continue  the  practice  of  utilizing  their  pupils 
to  earn  money  for  the  hospital  may  send  them  out  to 
private  cases  or  for  district  work  among  the  poor  for  a 
period  not  exceeding  three  months  in  the  third  year  of 
their  course." 

The  pupils  of  a  two  years'  course  are  not  permitted 
by  this  board  any  work  outside  the  hospital. 

On  the  question  of  the  hours  of  work  the  facts  themselves 
may  be  misleading.  On  the  face  of  it  an  eight-hour 
day  is  two-thirds  easier  than  a  twelve-hour  day.  In 


26  INTRODUCTION 

many  small  hospitals,  however,  the  average  work  is  light 
in  comparison  to  the  larger  hospitals,  the  average  opera- 
tions in  the  hospital  a  week  may  be  from  3  to  6,  instead  of 
50  and  upward,  to  one  operating-room.  The  number 
of  nurses  to  the  bed  may  be  in  the  same  proportion,  but 
in  the  smaller  hospital  it  will  frequently  be  found  that 
the  patients  convalesce  slowly,  lessening  greatly  the 
number  of  acute  cases,  with  their  demands  on  the  nursing 
staff.  A  twelve-hour  day  under  these  conditions  is 
often  less  exhausting  physically  and  mentally  than  eight 
hours  crowded  with  numerous  duties  and  serious  respon- 
sibilities. 

The  average  hours  now  required  of  a  pupil  nurse  are 
from  eight  to  ten,  with  a  twelve-hour  night  duty.  When 
the  day  is  over  eight  hours,  it  will  usually  be  found  that 
one  afternoon  a  week  without  duty  is  allowed.  On 
Sundays  the  average  day  is  six  hours. 

Some  consider  even  the  above  hours  too  long,  so  severe 
are  the  duties  at  present  expected  of  a  nurse,  and  so  much 
of  her  time  off  duty  is  required  for  study.  This  is  espe- 
cially stated  in  reference  to  the  twelve-hour  night  duty. 
In  a  few  hospitals  the  eight-hour  system  extends  also  to 
the  night  duty.  It  should  be  borne  in  mind,  on  the  other 
hand,  that  it  is  essential  that  the  physical  endurance  of  a 
nurse  should  be  adequately  tested.  Soldiers  are  taught 
to  march  in  times  of  peace.  Very  frequently,  indeed,  it 
is  a  matter  of  life  or  death  that  a  nurse  should  be  able  to 
endure  the  severest  physical  strain,  and  no  amount  of 
organization  can  prevent  these  emergencies  arising.  It 
would  seem  that  if  the  training  is  made  too  easy  in  respect 
to  the  length  of  time  on  duty,  the  best  means  of  testing 
a  pupil's  physical  fitness  is  lost.  She  may  spend  time  and 
energy  over  her  training  in  the  shelter  of  a  carefully 
organized  training-school,  to  find  later,  perhaps,  by  a 
serious  breakdown,  that  the  career  she  has  chosen  is 
far  beyond  her  physical  capabilities.  Such  tests  must, 
however,  to  be  justifiable,  be  accompanied  by  the  most 
vigilant  care  of  the  pupil's  health. 

The  question  of  salary  is  to  many  applicants  an  import- 
ant one.  The  average  age  of  admission  to  a  nurse's 


THE   CHOICE   OF   A  TRAINING-SCHOOL  27 

training  is  twenty-two  years.  In  a  large  number  of  cases 
the  applicant  has  supported  herself  for  periods  of  two,  four, 
and  sometimes  more  years.  The  self-respecting  wish  to 
continue  to  do  so  during  her  training  often  biases  her 
choice  in  favor  of  those  schools  giving  their  pupils  the  best 
remuneration.  She  should,  however,  understand  some 
of  the  ideas  that  control  the  regulation  of  such  remunera- 
tion before  coming  to  a  decision. 

It  must  be  remembered  that  a  training-school  is  not 
an  essential  part  of  a  hospital  force,  and  that  the  funds  at 
the  disposal  of  the  hospital  authorities  are  generally  willed 
and  contributed  for  the  purpose  of  maintenance  of  the 
hospital,  a  very  small  amount  in  any  case  has  hitherto 
ever  been  directly  given  to  the  training-school. 

A  modern  training-school  cannot  be  run  without  outlay. 
The  pupils  must  have  adequate  quarters,  class-rooms, 
equipment  for  instruction,  instructors  'specially  salaried, 
lecturers  who  are  also  in  the  best  schools  paid  for  their 
services;  frequently  there  is  a  preliminary  course  in  which 
the  pupil  is  not  available  for  the  general  work  in  the 
hospital,  and  at  the  present  day  such  luxuries  as  a  gym- 
nasium or  a  swimming-pool  are  a  not  infrequent  part  of 
the  nurses'  home.  The  conditions,  in  fact,  are  similar 
to  those  for  which  fees  are  paid  by  the  students  in  a  college 
or  a  technical  school.  Against  this  is  placed  the  fact 
that  the  pupils  do,  during  their  training,  the  work  of 
nursing  in  the  hospital,  in  return  for  which  the  hospital 
would  owe  them  board  and  lodging  and  some  salary, 
even  as  untrained  attendants;  they  could  not,  at  first,  be 
recognized  as  anything  else.1 

In  the  consideration  of  these  somewhat  conflicting 
conditions  the  different  governing  bodies  of  the  different 
hospitals  have  come  to  somewhat  varied  conclusions, 
all,  however,  agreeing  that  the  amount  expended  on  her 

1  It  may,  perhaps,  not  be  generally  known  that  when  training- 
schools  were  first  opened  in  England,  most  hospitals  received  a  sum 
from  each  pupil  for  her  board  and  lodging  and  the  use  of  the  hos- 
pital patients  and  supplies  for  her  instruction.  In  some  training- 
schools  this  condition  exists  to  the  present  day,  and  all  the  leading 
schools  have  a  number  of  paying  pupils.  The  fee  is  usually  $5.00 
a  week. 


28  INTRODUCTION 

education  should  have  weight  in  deciding  the  question  of 
salary  during  the  years  of  training. 

The  various  systems  may  be  classed  as  follows: 

Class  1:  No  remuneration  is  given.  The  pupil  pays 
a  premium  (usually  $50.00)  on  entrance  and  is  considered 
to  give  her  services  in  return  for  her  instruction.  Generally, 
connected  with  this  system,  scholarships  are  awarded 
of  varying  value  (from  $50.00  to  $400.00)  by  the  board 
of  trustees  of  the  hospital,  or  private  individuals  interested 
in  the  school,  which  materially  help  the  successful  student 
in  the  expenses  of  her  training,  or  enable  her  to  pursue 
special  studies  after  her  graduation. 

Class  2:  No  premium  is  exacted  and  no  remuneration 
given.  Scholarships  are  frequently  awarded. 

Class  3:  The  pupils  receive  a  salary  either  during  their 
entire  training  or  during  the  greater  portion  of  it.  In 
some  cases  scholarships  are  given,  not  generally  exceeding 
$50.00  in  value. 

The  salaries  in  this  class  vary  somewhat.  The  lowest  is 
$5.00  a  month  during  the  three  years;  the  highest  averages 
about  $5.00  a  month  the  first  year,  $8.00  the  second,  and 
$12.00  the  third.  A  few  give  $8.00  to  $10.00  during  the 
entire  training.  Investigation  has  shown  in  every  instance 
that  the  hospitals  offering  no  remuneration  spend  in  com- 
fortable quarters,  good  food,  equipment,  educational  ad- 
vantages, and  scholarships,  a  far  larger  sum  than  is  possible 
where  the  money  is  required  for  the  pupils'  salaries.  It  will 
usually  also  be  found  that  such  schools  are  in  advance  in 
educational  methods,  in  progressive  ideas,  and  in  care  of 
their  nursing  staff.  It  is,  in  effect,  frequently  the  case 
that  pupils  receive  more  that  is  essential  to  their  training, 
and  that  contributes  directly  to  the  success  of  their 
subsequent  career,  from  the  hospitals  that,  establishing 
their  training-school  on  a  collegiate  system,  give  no  sal- 
aries during  training,  than  is  the  case  in  the  majority  of  hos- 
pitals paying  salaries.  It  must  not  be  overlooked,  neverthe- 
less, that  many  hospitals  whose  training-schools  are  in  the 
first  rank  do  give  salaries,  recognizing  that  in  the  majority 
of  cases  it  is  a  matter  of  importance  to  the  pupil  to  be 
able  to  support  herself  from  the  beginning  of  her  training. 


THE   CHOICE   OF   A  TRAINING-SCHOOL  29 

In  the  above  attempt  to  put  before  the  pupil  the  more 
important  conditions  that  should  govern  her  in  deciding 
on  her  training-school,  reference  has  been  made  to  the 
"  affiliation  "  of  two  or  more  hospitals  in  order  to  give  their 
pupils  a  training  that  shall  fulfil  the  requirements  of  legal 
registration.  Some  further  elucidation  of  the  system  is 
perhaps  necessary. 

On  recalling  the  requirements  for  the  minimum  standard 
of  nurses'  instruction  it  will  readily  be  seen  that  many  of 
the  hospitals,  of  conditions  referred  to  above,  lack  alto- 
gether the  necessary  facilities  to  give  the  practical  instruc- 
tion. Such,  for  example,  are  the  special  hospitals  for  one 
disease  or  one  sex,  the  children's  hospitals,  the  accident 
and  emergency  hospitals,  and  the  small  general  hospitals 
whose  scope  of  work  is  restricted.  The  large  general 
hospitals  without  maternity  departments  may  also  be 
included. 

By  affiliation  the  material  in  two  or  more  hospitals  is 
used  for  the  instruction  of  one  set  of  pupils.  Thus  a 
large  general  hospital  may  send  its  pupils  for  a  course  in 
the  maternity  department  of  a  women's  hospital,  and  admit 
in  exchange  the  pupils  of  the  women's  hospital  to  their 
male  wards.  A  small  general  hospital  may  send  its  pupils 
to  an  active  special  hospital,  say,  for  gynecology  or  acci- 
dent work,  and  in  return  receive  pupils  from  the  special 
hospitals.  At  the  present  day  it  is  the  only  way  in  which 
the  question  of  using  the  special  hospital  for  training-schools 
has  been  at  all  satisfactorily  solved,  and  is  probably  but 
the  beginning  of  a  movement  which  may  develop  in  several 
ways.  That  most  generally  anticipated  is  the  establish- 
ment of  central  nursing  schools,  which  shall  take  the  control 
of  the  nursing  in  several  hospitals  and  use  them  for  the 
instruction  of  their  pupils,  a  practice  already  in  vogue  in 
some  parts  of  Europe. 

In  conclusion,  those  who  contemplate  embracing  a 
nurse's  career  cannot  be  too  strongly  urged  to  choose 
wisely  their  training-school.  If  it  is  not  the  most  vital 
step  of  her  life,  it  is,  at  least,  one  that  must  affect  strongly 
her  whole  future  career,  her  character,  her  development, 
and  her  opportunity  for  future  usefulness. 


30  INTRODUCTION 

QUALIFICATIONS   OF  A  NURSE 

In  viewing  the  qualifications  of  a  candidate,  the  various 
items  that  compose  her  fitness  or  her  disqualification  may 
be  considered  under  four  headings:  character,  physique, 
education,  and  social  state. 

It  is  the  custom  in  most  training-schools  to  take  the 
greatest  pains  to  obtain  reliable  information  on  these 
points.  Each  candidate  has  a  set  of  questions  sent  her, 
the  answers  to  which  should  give  all  the  principal  facts  of 
her  previous  life,  especially  in  reference  to  her  health, 
her  education,  and  the  manner  in  which  she  has  occupied 
herself  since  she  left  school.  She  is  required  to  send  a 
certificate  of  physical  fitness  from  her  doctor,  and  another 
from  her  clergyman  to  testify  to  her  moral  standing. 
These  are  further  supplemented  by  confidential  letters  to 
two  or  more  friends  of  the  applicant  from  a  list  supplied  by 
herself.  In  cases  where  it  is  practical,  a  personal  inter- 
view is  also  insisted  on. 

In  spite  of  care,  however,  such  information  is  often 
misleading,  and  sometimes  wilfully  dishonest.  Facts 
detrimental  to  a  woman's  character  are  withheld,  especi- 
ally by  friends,  apparently  from  the  point  of  view  of  help- 
ing a  fellow  creature  toward  a  fresh  start.  It  has,  there- 
fore, become  customary  to  admit  a  candidate  in  the  first 
place  to  a  term  of  probation  or  novitiate,  placing  her  for 
that  period  in  conditions  which  shall  test  her  fitness  for 
the  profession  for  which  she  proposes  to  qualify  herself. 
The  period  varies,  in  different  schools,  from  two  months  to 
six  months,  three  months  being  a  common  requirement. 
In  view  of  the  strangeness  of  the  conditions  surrounding  her, 
the  exacting  character  of  her  duties,  and  the  physical  and 
mental  strain  they  imply,  the  probation  is  a  wise  institu- 
tion, both  on  the  part  of  the  school  authorities  and  in  the 
interests  of  the  pupil.  In  order  to  develop  pupils  have  first 
to  adapt  themselves  to  the  new  conditions,  and  all  who 
have  watched  generations  of  probationers  will  agree  that, 
as  a  rule,  those  possessing  the  finest  qualifications  of  mind 
and  character  are  usually  the  slowest  to  adapt  themselves 
to  new  conditions.  Frequently  a  pupil  only  begins  to 


QUALIFICATIONS    OF    A    NURSF,  31 

show  the  possibilities  she  possesses  toward  the  end  of  her 
probation.  On  the  other  hand,  if,  at  the  end  of  her  pro- 
bationary term,  no  aptitude  for  the  work  has  developed, 
it  may  fairly  be  presumed  that  the  pupil  has  mistaken 
her  calling. 

Physical  Qualifications. — An  average  condition  of  good 
health  is  an  essential  for  any  work  implying  physical 
strain.  Before  entering  the  school  the  heart  and  lungs 
should  be  examined,  the  eyes  tested,  and  the  teeth  put 
in  good  order.  Delicate  health,  even  if  a  pupil  succeeds 
in  finishing  her  training  without  a  breakdown,  will  always 
be  a  drawback  to  success  in  her  career,  and  is  likely  to  be 
aggravated  by  the  conditions  in  which  her  work  must 
be  performed.  The  delicacy  that  arises  from  over-indul- 
gence at  home  or  lack  of  occupation  is  another  matter. 
In  nine  cases  out  of  ten  the  occupation,  interest,  and  regu- 
larity of  life  prove  the  best  of  tonics  for  such  women. 

It  is  not  usual  to  admit  a  pupil  to  training  before  she  is 
twenty-two  years  of  age.  Physically  this  is  a  sound  decis- 
ion. The  confinement  indoors,  the  small  opportunity 
for  recreation,  the  incessant  demand  on  her  physical  and 
mental  resources,  may  certainly  be  considered  as  condi- 
tions adverse  to  her  best  development,  and  are  a  severe 
strain  on  an  organization  hardly  mature.  Bearing  in 
mind  also  the  responsible  character  of  the  work,  the 
immense  importance  of  such  qualities  as  discretion  and 
judgment,  there  are  many  grave  objections  to  graduation 
under  twenty-five  years  of  age. 

On  the  other  hand,  investigation  shows  that  a  large 
percentage  of  women  who  enter  the  profession  do  so  in 
order  to  make  a  livelihood.  Very  frequently,  indeed, 
it  is  necessary  for  her  to  begin  to  earn  her  living  no  later 
than  eighteen.  The  choice  of  means  to  do  so  is  limited — 
teaching,  stenography,  book-keeping,  or  industrial  occu- 
pations. Probably  were  the  hospital  training-schools 
also  open  to  her,  a  much  larger  number  of  women  would 
seek  to  qualify  themselves  as  nurses  than  is  at  present  the 
case.  By  the  time  they  are  twenty-two  the  majority 
are  disinclined  to  make  a  change  in  their  occupation,  es- 
pecially if  they  are  earning  enough  to  make  themselves 


32  INTRODUCTION 

independent,  while  those  that  do  are  apt  to  find  the 
necessary  restrictions  and  discipline  of  school  life  distaste- 
ful after  the  independence  to  which  they  have  become  used. 

The  question  of  age  limit  seems  one  in  which  the  personal 
equation  might  count  for  more  than  is  at  present  the  case. 
There  are  women  who  have  more  stability  at  twenty- 
one  than  many  others  at  twenty-five.  For  women  whose 
circumstances  do  not  compel  them  to  seek  a  livelihood  by 
nursing  twenty-two  is,  however,  quite  early  enough. 
After  thirty-five  women  are  usually  discouraged  from 
beginning  so  exacting  a  calling.  Undoubtedly,  however, 
the  decision  in  such  cases  should  be  guided  by  the  individ- 
ual circumstances,  and  by  the  motive  that  has  induced 
the  choice. 

At  the  end  of  the  probation  it  is  customary  to  subject 
the  pupils  to  a  second  physical  examination  before  their 
final  admission  to  the  school,  and  usually  this  is  performed 
by  one  of  the  visiting  physicians  who  has  the  health  of  the 
nurses  under  his  special  care.  A  special  book  in  which 
the  results  of  the  examination  are  written  and  signed  by 
the  examiner  is  of  value  for  reference  should  a  pupil  at 
a  later  period  break  down.  Sufficient  space  should  be 
kept  under  each  pupil's  name  for  an  account  of  any  sickness 
she  may  have  during  her  training. 

Character. — In  few  callings  has  the  character  of  the 
individual  so  much  to  do  with  her  success  or  failure  as  in 
the  profession  of  nursing.  Knowledge  and  skill  may  be 
acquired  by  all,  and  yet,  however  equal  the  pupils  may  be 
in  these  respects,  it  will  always  be  found  that  the  personal 
equation  will  make  all  the  difference  between  success  and 
failure,  and  it  will  invariably  be  found  that  the  qualities 
required  and  most  esteemed  are  the  simple  fundamental 
qualities  of  honesty,  industry,  perseverance,  intelligence, 
and  high  moral  principles.  One  might  add,  but  for  its 
rarity,  the  supreme  qualification  of  common  sense.  Given 
these,  the  more  especial  attributes  of  sympathy,  unsel- 
fishness, tact,  observation,  judgment,  discretion,  and  good 
manners  may  even,  if  apparently  absent  at  first,  very  fre- 
quently be  developed  by  the  training  and  the  demands  of 
the  work. 


QUALIFICATIONS   OF   A   NURSE  33 

With  the  above  fundamental  basis,  few  vocations  open 
to  women  have  such  a  marked  value  in  developing  the 
best  parts  of  a  woman's  character  as  a  course  in  a  good 
training-school.  Nothing  is  less  true  than  that  nursing 
as  a  profession  necessarily  hardens  a  woman,  in  many 
instances  makes  her  coarse,  indelicate,  and  wanting  in 
sympathy.  Rather  is  her  work  a  perpetual  education, 
if  only  from  the  point  of  view  of  perpetually  demanding 
her  best. 

While  not  looking  for  perfection  among  a  class  of  pro- 
bationers, there  are,  nevertheless,  some  temperamental 
shortcomings  that  should  be  considered  to  disqualify,  so 
surely  do  they  lead  to  mischief,  and  so  certainly  does  the 
little  leaven  spread  among  the  pupils.  An  inherent  un- 
truthfulness,  flippant  and  flighty  behavior,  any  tendency 
toward  lack  of  sobriety  or  moral  slackness,  are  defects  it 
is  beside  the  question  to  grapple  with  in  a  training-school. 
For  every  reason  women  admitted  to  a  training-school 
should  be  able  to  show  a  perfectly  pure  record  of  their 
previous  life.  A  training-school  is  not  a  place  in  which  to 
retrieve  a  dubious  past. 

Education. — At  the  present  day,  when  the  primary 
use  of  the  training-school  is  to  establish,  on  a  firm  basis, 
nursing  as  a  profession  for  women,  and  especially  for 
women  of  education,  the  preliminary  education  of  an 
applicant  is  considered  an  important  qualification.  In 
future  years  we  shall  probably  realize  that,  since  sickness 
is  as  common  as  maternity,  sound  instruction  in  methods 
of  nursing  should  be  available  for  any  woman  who  wishes 
to  learn  how  to  nurse,  and  more  especially  for  those  women 
of  the  working  classes  who  are  unable  to  pay  for  a  trained 
nurse  and  must,  therefore,  in  many  instances  do  their 
nursing  themselves.  It  will  be  remembered  that  in  many 
districts  there  are  no  hospitals  where  infectious  diseases 
are  admitted,  that  measles  and  whooping-cough  are  not 
generally  admitted  even  to  infectious  hospitals,  and 
that  to  incurable  cases,  in  America,  only  the  almshouses 
are  open.  These  cases  are  nursed  in  the  home.  Thou- 
sands of  women  would  have  the  daily  burden  of  their  life 
immensely  lightened  if  they  knew  how  to  perform  the  many 
3 


34  INTRODUCTION 

offices  of  nursing  the  sick.  At  present  there  is  no  place 
where  such  women  can  learn.  Even  if  their  education 
came  up  to  required  standards,  they  are  usually  married 
long  before  they  are  twenty-two. 

Where  a  standard  of  preliminary  education  is  required 
for  legal  registration,  we  find  the  minimum  requirement 
to  be  a  "  grammar-school  course  or  its  equivalent"  (Cali- 
fornia), while  the  maximum  exacted  is  a  "  high-school 
education  or  its  equivalent  "  (Maryland,  Indiana,  West 
Virginia).  The  State  Regents  of  New  York  require 
"  one  year  of  high  school  subsequent  to  an  eight-year 
grammar-school  course  or  its  equivalent."  Other  States 
simply  exact  evidences  of  sufficient  preliminary  education. 

Other  points  being  equal,  a  good  preliminary  educa- 
tion is  an  asset  that  opens  out  to  its  possessor  a  solid 
possibility  of  future  success  in  her  career. 

As  we  have  pointed  out,  the  training-school  is  the  place 
where  a  woman  is  prepared  for  every  branch  of  usefulness 
in  which  a  knowledge  of  nursing  is  a  required  part.  Every 
year  fresh  fields  of  usefulness  are  opening  before  us,  and 
the  old,  well-trodden  ways  develop  increasing  demands  on 
the  brain  and  capabilities  of  those  who  would  tread  them. 
Besides  fitting  a  woman  for  private  nursing,  her  training 
prepares  her  to  undertake  the  responsibility  and  super- 
intendence of  the  various  departments  connected  with 
the  nursing  in  the  hospital.  She  is  trained  to  act  as 
head  nurse  in  a  ward,  in  an  amphitheater,  as  night  super- 
visor, a  post  of  the  greatest  responsibility,  as  instructress 
of  one  or  other  class,  or  as  supervisor  in  one  or  other  of 
the  domestic  departments;  finally,  in  due  time,  she  should 
be  capable  of  filling  the  post  of  superintendent  of  nurses, 
with  its  exacting  demands  on  her  intellectual  resources. 

Outside  the  hospital  world  it  is  being  realized  that  a 
nurse's  training  fits  a  woman  for  many  branches  of  civic  use- 
fulness. Nurses  are  prominent  in  the  organizing  of  special 
campaigns  against  tuberculosis  by  visiting  the  patients, 
spreading  sound  knowledge  of  the  treatment  required,  and 
the  precautions  necessary  to  prevent  its  spread.  Nurses 
are  proving  their  immense  helpfulness  in  the  public  schools, 
where  not  only  are  small  matters  of  cuts  and  sores  properly 


QUALIFICATIONS   OF   A   NURSE  35 

attended  to,  early  stages  of  infection  detected,  and  general 
matters  of  bodily  cleanliness  enforced,  but  the  develop- 
ment of  backward  children  is  enormously  helped  by  such 
means  as  attention  to  defective  vision,  deafness,  the 
removal  of  adenoids,  and  so  forth.  In  hardly  any  branch 
of  a  nurse's  career  does  she  see  such  immediate  satisfactory 
returns  for  her  labor  as  in  school  nursing.  We  have 
nurses  as  factory  inspectors,  nurses  on  school-boards  and 
boards  of  guardians,  nurses  as  public  lecturers  on  hygiene 
and  allied  subjects,  nurses  owning,  controlling,  and  edit- 
ing papers  and  magazines,  nurses  as  authoresses,  nurses 
organizing  public  movements,  such  as  an  international 
conference,  and  active  in  the  smaller  matter  of  organiza- 
tion in  their  own  alumna?  associations.  Nurses  in  the 
mission  fields,  nurses  in  settlement  work,  nurses  in  the 
army,  are  perhaps  more  familiar  ideas,  but  it  is  not  so 
readily  understood  that  women  in  all  the  branches  enum- 
erated are  doing  work  for  which  their  training-school  has 
fitted  them,  and  in  which,  nevertheless,  the  actual  tend- 
ing of  the  sick  is  but  one  part,  and  even  in  some  instances 
not  the  chief  part.  The  work  that  nurses  have  done  in 
the  hospitals  in  introducing  order,  method,  decency,  and 
skill  where  before  were  chaos,  ignorance,  and  often  vice, 
is  so  well  known  that  it  is  taken  as  a  matter  of  course  and 
practically  forgotten.  But  this  work  is  still  going  on — 
to  those  who  look  far  only  the  first  few  steps  have  been 
taken ;  whether  the  further  goals  are  reached  depends,  in  a 
great  measure,  on  the  quality  of  the  women  we  train. 

More  and  wider  fields  are  opening  for  nurses  everyday, 
but  enough  has  been  said  to  point  out  that  education  and 
brains  are  a  necessity  if  the  many  phases  of  modern  nurs- 
ing are  to  be  developed.  The  standards  of  education 
enumerated,  it  must  be  remembered,  are  minimum  stand- 
ards. The  best  education,  the  most  thorough  and  the 
broadest,  is  not  wasted  in  the  profession  of  nursing. 
Realizing  this,  the  schools  that  are  in  advance  in  methods 
of  teaching  enforce  a  standard  of  instruction  in  itself  of 
educational  value,  in  order  further  to  supplement  the 
frequently  defective  early  education,  and  encourage 
among  the  pupils  the  pursuit  of  studies  not  apparently 


36  INTRODUCTION 

germaine  to  the  work  of  a  nurse.  Such  schools  bear  the 
largest  share  in  the  effort  to  equip  women  to  take  their 
part  in  the  fields  of  usefulness  opening  out  before  those 
who  have  had  training  in  nursing.  Their  methods  are 
frequently  criticized,  especially  by  members  of  the  medical 
profession  who  meet  nurses  chiefly  in  their  private  work, 
and  who  profess  not  to  recognize  any  need  for  their  higher 
education.  The  j  ustification  of  the  methods  of  these  schools 
may  be  derived  from  an  investigation  of  the  work  of  their 
graduates.  In  the  majority  of  instances  the  women  who 
are  coming  to  the  fore  in  one  or  other  of  the  fields  of  work 
already  instanced,  and  who  are,  with  prophetic  instinct, 
opening  out  new  fields  of  social  utility,  are  the  women  who 
have  been  trained  in  the  schools  of  broad,  progressive, 
educational  standards.  Where  a  woman  is  able  and 
qualified  to  enter  such  a  school,  she  is  availing  herself  of 
her  best  possible  chance  of  future  development  by  so 
doing. 

Social  State. — As  regards  the  social  state  of  a  woman  in 
relation  to  her  career  as  a  nurse,  a  few  words  only  are 
necessary.  Undoubtedly,  it  is  a  career  that  demands 
disinterestedness,  and  that  frequently  exacts  the  sacrifice 
of  every  other  sentiment  to  the  fulfilment  of  duty.  Often 
this  may  entail  the  remaining  at  the  post  of  duty  regardless 
of  any  other  consideration.  It  would,  therefore,  seem 
that  for  a  woman  to  have  already  existing  obligations, 
such  as  those  necessitated  by  husband  and  children,  may 
be  a  serious  hindrance  in  her  work.  She  may  find  her- 
self in  circumstances  when,  if  she  obeys  the  dictates  of 
her  natural  instincts,  she  must  forego  the  demands  of 
duty,  and  she  cannot  perform  the  duty  without  violence 
to  those  instincts,  and  injustice  to  those  for  whose  welfare 
she  feels  herself  primarily  responsible.  And  this  may 
happen  not  once,  but  many  times.  The  sacrifice  of  the 
home  to  his  duty  is  a  common  experience  in  the  life  of  a 
man,  but  the  sentiment  of  public  feeling,  of  his  own  con- 
science, is  with  him  while  so  doing,  even  were  his  presence 
in  the  home  of  the  same  value  as  that  of  the  wife  and 
mother.  With  a  woman  the  case  is  reversed.  She  might, 
from  a  high  sense  of  duty,  brave  the  violence  to  her  own 


QUALIFICATIONS   OF   A   NURSE  37 

feelings,  but  she  will  not  incur  the  misunderstanding  of 
such  an  act  on  the  part  of  those  to  whom  she  is  bound  by 
the  strongest  ties  of  nature. 

It  would,  therefore,  seem  that  there  are  strong  reasons 
for  dissuading  a  married  woman  with  either  husband  or 
children  alive  from,  whatever  the  motive,  taking  up  nursing 
as  a  career.  The  nature  of  its  work  makes  its  calls  often 
as  exacting  as  are  the  vows  of  a  nun,  and  it  is  best  for 
such  women,  if  circumstances  compel  them,  to  seek  other 
careers. 

A  widow  without  children,  on  the  other  hand,  has  no 
more  calls  than  an  unmarried  woman,  and  may  frequently 
find  in  the  claim  of  a  community  life,  in  the  human  inter- 
est which  surrounds  her  work,  in  the  training  and  helping 
of  the  younger  nurses,  or  the  nursing  of  young  children,  a 
life  in  which  the  relationships  are  more  human,  and  which, 
in  the  demands  it  makes  upon  herself,  have  more  in  com- 
mon with  the  natural  home  vocation  than  in  any  other 
work  she  may  undertake. 

For  the  unmarried  woman  it  is  a  career,  as  has  been 
shown,  of  much  varied  interest.  Few  realize  until  they 
actually  embrace  it  the  absorbing  interest  of  hospital 
work.  We  hear  much  about  the  confinement,  the  hard- 
ships, the  discipline  of  the  life,  and  little  of  the  many 
reasons  why,  in  the  past  half  century,  the  work  has  ap- 
pealed and  still  appeals  to  an  enormous  number  of  women 
of  widely  diverse  temperament,  and  varied  social  and 
educational  standing.  The  workers  are  rarely  the  talkers, 
and  probably  many  would  be  at  a  loss  to  enumerate  the 
conditions  that  specially  appeal  to  them  in  hospital  work. 
Assuredly  it  is  not  pure  philanthropy.  Few  are  philan- 
thropists until  thought  and  circumstances  have  made 
them  so,  and  the  large  majority  begin  nursing  before  their 
twenty-fifth  year. 

It  may  be  conceded  that  nursing  is  woman's  work. 
It  is  perhaps  the  only  calling  in  which  she  is  left  in 
undisputed  possession  of  the  field.  Man  may  work  with 
her  or  against  her  in  suggesting  methods,  prescribing 
conditions,  or  criticizing  results,  much  as  he  may  do  where 
the  subject  is  the  rearing  of  children,  but  on  the  field  of 


38  INTRODUCTION 

the  actual  work  he  does  not  encroach.  It  is  a  tacit  con- 
fession that  for  nursing  the  natural  qualities  of  a  woman 
are  wanted. 

COMMERCIAL  VALUATION 

While  in  speaking  of  nursing,  and  especially  hospital 
nursing,  we  use  the  terms  "  calling,"  "  vocation,"  almost 
as  frequently  as  "  profession,"  nevertheless  the  term  pro- 
fession most  nearly  describes  the  conditions  under  which 
modern  nurses  aspire  to  work.  Nursing  is  not  rightly 
understood  where  it  is  classed  as  the  feminine  half-way 
house  between  the  clergyman  and  the  doctor.  It  is  a 
definite  work,  requiring  definite  training,  and  although 
in  its  pursuit  the  opportunities  for  philanthropic  work 
are  manifold,  just  as  they  are  in  the  calling  of  a  clergy- 
man or  the  profession  of  a  doctor,  it  is  fair,  in  investigating 
nursing  as  a  profession,  to  apply  to  it  similar  tests  to  those 
that  hold  good  in  other  professions. 

Can  nursing  insure  one  a  livelihood?  Does  one  receive 
a  fair  percentage  for  one's  outlay?  Is  it  a  profession  that 
can  be  pursued  for  an  indefinite  period?  What  possibility 
is  there  of  saving  for  the  inactive  years  of  old  age?  How, 
in  these  respects,  does  it  compare  with  other  professions 
open  to  women,  such,  for  example,  as  medicine  or  teaching? 
or  with  the  wage-earning  occupations,  such  as  stenography, 
book-keeping,  or  working  in  a  store? 

As  compared  with  the  professions,  nursing  has  this  im- 
mense advantage,  that  the  knowledge  may  be  acquired 
with  but  little  outlay.  The  most  asked  of  a  pupil  is,  as 
has  been  said  before,  a  small  premium  and  to  forego  earn- 
ing money  for  the  three  years  of  her  training,1  in  return  for 
which  she  receives  board,  lodging,  laundry,  care  in  sick- 
ness, and  all  the  instruction  necessary  to  equip  her  for 
the  profession  by  which  she  is  to  earn  her  living.  It  is  also 
always  in  her  power  to  enter  a  school  that  does  give 
some  remuneration  during  the  training.  In  preparing 
for  a  profession,  for  example,  medicine  or  teaching,  an 
outlay  is  inevitable.  In  medicine,  during  the  course  of 
four  years  the  student  must  pay  out  for  board,  lodging, 
1  American  standards  only  are  discussed. 


COMMERCIAL    VALUATION  39 

tuition  fees,  and  material  for  work  a  sum  of  not  less  than 
$500  a  year,  while  any  extra  expense  of  sickness  must  be 
a  further  drain  on  her  resources.  The  same  is  true  of  the 
profession  of  teaching.  The  college  expenses  may  be 
kept  down  in  most  places  to  $500  a  year  for  four  years; 
in  some  of  the  small,  non-residential  colleges  even  to  $400, 
but  there  are  the  four  months'  annual  vacation  to  be 
considered,  with  the  necessary  outlay  for  board  and 
lodging.  And  it  must  be  remembered  that  these  figures 
represent  minimum  sums  and  entail  the  practice  of  a 
rigid  economy  that  amounts  to  deprivation  on  the  part 
of  the  student. 

The  condition  of  apprenticeship  to  the  wage-earning 
occupations  for  women  are,  of  course,  less  stringent 
financially.  Still,  the  stenographer  or  book-keeper  has 
to  spend  months  in  learning  her  work  and  pay  out  sums 
for  tuition  before  she  can  receive  the  smallest  return  for 
her  outlay,  during  all  of  which  time  she  must  depend  on  her 
own  resources  for  board  and  lodging,  and  incur  incidental 
expenses,  such  as  laundry,  from  which  the  hospital  pupil 
is  exempt.  The  shop  or  factory  girl,  milliner,  or  dress- 
maker in  many  instances  may  begin  to  earn  at  once, 
though  not  in  the  best  businesses,  which  are  the  natural 
fields  for  advancement.  Her  salary  is,  however,  far  too 
small  to  give  her  anything  like  the  same  quality  of  board 
or  lodging  provided  for  the  student  nurse  during  the  three 
years  in  which  she  is  either  not  earning,  or  earning  only  a 
small  amount. 

In  preparing  for  her  profession  the  student  nurse  has 
then  in  each  instance  a  decided  advantage  financially. 

At  the  end  of  the  three  years  a  nurse  is  in  a  position 
to  earn  her  own  living,  and,  what  is  more,  is  practically 
certain  of  the  immediate  opportunity  of  so  doing.  The 
medical  student  and  the  college  girl  still  have  a  year's 
work,  with  its  financial  outlay,  before  them,  at  the  end  of 
which  period  it  cannot  be  said  that  they  are  certain  of 
obtaining  work  that  will  insure  them  a  competency.  The 
medical  student  has,  in  all  probability,  years  of  waiting 
and  hard  work  still  to  look  forward  to,  while  the  college  girl 
finds  that,  for  the  best  posts,  there  is  acute  competition. 


40  INTRODUCTION 

To  the  graduate  nurse  two  ways  of  pursuing  her  pro- 
fession as  a  means  of  livelihood  are  open — private  nursing 
and  institutional  work.  The  fees  of  a  private  nurse  are 
from  $20  to  $25  a  week,  with,  besides,  board,  lodging, 
and  laundry  while  she  is  with  a  case.  The  salaries  of 
graduate  nurses  in  a  hospital  usually  begin  at  $30  a  month 
for  a  ward  head  nurse,  increasing  to  $40  or  $50  for  those 
posts  considered  more  onerous,  such  as  amphitheater  nurse 
or  night  supervisor,  and  finally  rising  to  from  $60  to  $75 
when  sufficient  experience  has  been  gained  to  fit  the  nurse 
to  act  as  instructress  of  a  class  or  head  of  one  of  the  various 
departments,  educational  or  domestic,  under  the  super- 
intendent of  nurses.  She  receives  board,  lodging,  and 
laundry,  her  full  salary  during  her  annual  vacation,  and 
medical  service  and  nursing  in  case  of  illness. 

To  the  nurse  newly  graduated  it  almost  always  appears 
that  private  nursing  is  the  more  lucrative  career,  and  it 
must  be  understood  we  are  at  present  considering  the 
question  purely  from  the  standpoint  of  financial  return. 
To  her,  $25  a  week  is  $100  a  month;  she  allows  in  her 
imagination  two  months  out  of  a  year  for  vacation  and 
lack  of  cases,  and  still  sees  herself  in  receipt  of  an  income  of 
$1000  a  year,  and  she  compares  it  favorably  with  the  $360 
which  usually  represents  the  first  year's  salary  of  the 
hospital  nurse. 

In  comparing  the  conditions  some  facts  must  be  con- 
sidered other  than  the  actual  amount  received  in  salary 
or  fees.  We  must  consider  the  sums  one  or  other  may  be 
obliged  to  pay  out,  the  steadiness  of  the  work,  and  the  prob- 
able duration  of  time  in  which  the  graduate  may  expect 
to  remain  in  active  work.  We  shall  see  that  these  points 
are  mostly  in  favor  of  the  hospital  nurse. 

The  private  nurse  must  own  a  room  in  which  to  have 
her  belongings  and  to  which  calls  can  be  sent.  Either 
she  belongs  to  a  nurse's  club,  or  she  rents  a  room  by  her- 
self or  with  one  or  two  other  nurses.  The  minimum 
which  she  can  pay  for  such  a  room  is  $2  a  week,  or  $104  a 
year.  When  she  is  not  at  work,  her  board  will  cost  her  a 
further  outlay  of  at  least  $5  a  week,  including  laundry, 
and  will  be  much  more  if  she  means  to  live  comfortably. 


COMMERCIAL    VALUATION  41 

Even  if  she  is  in  constant  work  her  own  health  will  demand 
that  she  does  no  nursing  for  two  months  out  of  twelve. 
The  minimum  cost  for  the  two  months  cannot  be  reckoned 
at  less  than  $45.  Other  expenses  not  so  easy  to  estimate 
are  her  journeys,  which,  unless  she  accompanies  a  patient, 
are  frequently  at  her  own  expense,  and  the  outlay  on  dress 
that  her  work  entails.  On  the  last  item  far  more  than  is 
necessary  is  usually  spent;  still,  in  many  cases  clothes 
she  would  have  otherwise  little  use  for  are  necessary  to 
the  private  nurse.  She  may  be  obliged  to  accompany  a 
nervous  patient  to  fashionable  resorts  where  it  is  not  desir- 
able to  appear  in  uniform,  to  dine  at  hotel  table  d'hote, 
to  be  with  the  patient  at  opera  and  theater,  or  travel  with 
her  weeks  at  a  time.  In  all  these  circumstances  she  must 
dress  appropriately,  however  quietly. 

The  corresponding  outlay  of  the  hospital  nurse  is  very 
small.  Her  only  necessary  expense  is  her  yearly  holiday, 
during  which  time  she  receives  her  salary  as  usual.  Her 
wardrobe  can  really  be  reduced  to  her  uniforms,  a  street 
suit,  and  another  dress  for  theater  or  party  wear,  and  as 
she  usually  dresses  in  uniform  indoors,  may  reasonably 
last  a  long  time.  It  is  not  only  practical,  but  easy,  for 
her  to  lay  by,  even  in  her  first  year,  some  of  her  salary. 

To  compare  the  conditions  truly,  however,  it  is  necessary 
to  compare  the  receipts  and  expenditures  over  a  longer 
period. 

It  is  said  that  the  average  active  life  of  a  private  nurse 
lasts  ten  years,  and  that  her  average  income  during  that 
time  is  $700  a  year.  This  is,  of  course,  taking  unsuccessful 
nurses  with  successful,  and  good  years  with  bad  years. 
At  the  end  of  ten  years,  or  fifteen  at  the  most,  a  private 
nurse  will  find  that,  for  active  practice,  she  is  superseded  by 
the  graduate  fresh  from  hospital,  with  the  newest  methods 
at  her  fingers'  ends.  She  has  longer  periods  of  inactivity, 
each  week  of  which  lessens  her  income  by  $25.  In  many 
cases  she  settles  down  with  a  case  of  chronic  invalidism, 
where  her  position,  half  companion,  half  caretaker,  can 
hardly  be  considered  to  have  professional  status.  Her 
ambitions  are  dead,  there  is  little  to  look  forward  to  but 
one  such  case  after  another,  until  she  is  forced  to  retire 


42  INTRODUCTION 

on  what  she  has  been  able  to  save  in  the  earlier  days  of 
her  career.  Unfortunately,  her  best  earning  days  have 
been  her  earliest,  the  period  at  which  very  few  realize 
the  practical  necessity  of  saving  for  future  years. 

The  hospital  nurse  may  be  said  to  begin  at  the  other 
end,  while  each  year  she  remains  at  her  work  increases 
her  value.  If  $30  a  month  represents  her  first  year's 
salary,  this  is  her  lowest  year.  By  her  third  year  she  is 
probably  earning  $50,  even  at  a  conservative  valuation. 
By  this  time  she  has  required  sufficient  experience  to  fit 
her  for  the  post  of  superintendent  of  nurses  in  a  small 
school,  or  assistant  superintendent  in  a  larger  one.  Her 
salary  in  either  case  will  be  from  $600  to  $1000  a  year. 
As  superintendent  of  nurses  in  the  larger  schools  she  will 
receive  from  $1000  to  $1500  a  year.  It  must  be  remem- 
bered, too,  that  in  these  posts  she  has  also  her  own  quarters, 
and  board,  service,  and  laundry,  all  on  a  scale  that  would 
cost  her  at  least  from  $700  to  $900  a  year,  and  probably 
considerably  more  had  she  to  provide  it  herself.  She  has, 
besides,  the  advantage  of  the  best  medical  advice  and 
nursing  in  case  of  sickness,  nor  do  temporary  illness  or 
her  summer  vacation  entail  a  corresponding  loss  of  salary. 

At  the  end  of  ten  years,  then,  the  hospital  nurse  may 
reasonably  expect  to  find  herself  earning  a  salary  of  from 
$1000  to  $1500  a  year  with  absolutely  no  expenses  except 
personal  ones,  and  with  nothing  but  the  limitations  of  her 
own  health,  or  capacity  for  work,  to  prevent  her  remaining 
at  her  post  for  a  practically  indefinite  period .  Many  women 
have  held  such  posts  for  ten,  twenty,  and  thirty  years. 
It  is  also  reasonable  to  remember  that,  as  in  the  majority 
of  cases,  such  posts  necessitate  an  amount  of  constructive 
work  at  the  beginning,  the  early  years  are  usually  the 
hardest.  Later,  as  the  work  of  careful  organization  bears 
fruit,  the  physical  and  practical  labor  is  less,  while  there 
is  greater  demand  for  the  qualities  of  judgment  and  control, 
the  natural  outcome  of  ripe  experience.  With  an  assured 
income  it  is  now  possible  to  put  by  a  sum  every  year  for 
the  years  of  inactivity,  while  still  spending  sufficient  on 
reasonable  recreation,  traveling,  and  other  forms  of  wise 
self-development. 


COMMERCIAL   VALUATION  43 

Ten  years  after  graduation  the  medical  woman  has  no 
such  assurance  of  financial  security;  in  her  profession  the 
few  win  the  prizes;  to  the  majority  the  year's  income  is 
a  precarious  asset,  obtained  only  by  acute  competition, 
and  never  secure.  In  the  college  world  the  good  posts 
bring  from  $2000  to  $3000  a  year,  out  of  which  all  living 
expenses  must  be  paid.  These  posts  are  comparatively 
few  in  number,  and  usually  given  only  to  women  who,  by 
original  work  or  exceptional  gifts,  have  proved  themselves 
to  excel  over  their  contemporaries.  Usually  they  have 
spent  comparatively  unremunerative  years  in  fitting  them- 
selves for  their  special  branch  of  study  and  educating 
themselves  meanwhile  by  travel  and  research.  The 
majority  of  the  successful  earn  from  $1000  to  $1500  as 
teachers  in  first-class  schools,  again  with  all  their  living 
expenses  to  come  out  of  their  income,  and  many  less 
adequately  fitted  for  their  career  earn  sums  considerably 
below  these  figures  as  teachers  in  the  lower  grade  schools. 

In  the  wage-earning  occupations  there  are  fewer  oppor- 
tunities for  advancement,  men  being  as  business  heads 
of  departments  nearly  always  more  successful  than  women, 
and  preferred  before  them.  With  an  exceptional  business 
ability  a  woman  may  make  a  success  as  buyer  to  a  large 
department,  or  forewoman  in  a  first-class  establishment, 
or,  provided  she  has  capital  to  invest,  by  undertaking  a 
business  venture  of  her  own.  It  must  be  realized,  how- 
ever, again  that  the  success  is  the  exception,  the  major- 
ity of  wage-earners  considering  themselves  well  off  if 
their  salaries  bring  them  $50  to  $75  a  month,  from  which 
their  living  expenses  must  be  deducted,  and  many  work 
for  much  less. 

A  comparative  estimate  of  these  conditions  shows  that 
from  the  financial  basis  much  may  be  said  in  favor  of  a 
hospital  nurse's  career.  At  present  the  conditions  are 
favored  by  the  fact  that  the  supply  of  women  capable 
of  filling  the  posts  is  less  than  the  demand.  In  Europe, 
and  especially  in  England,  the  movement  of  special  train- 
ing in  nursing  came  primarily  from  women  of  leisure  and 
education  and  assured  social  position,  who  found  in  the 
organization  and  direction  of  hospitals  and  nurse  schools 


44  INTRODUCTION 

a  natural  bent  for  their  energies.  In  the  American  move- 
ment such  women  were  the  exception.  While  there  were 
a  sufficient  number  to  act  as  leaders,  the  large  majority 
of  American  nurses  were  and  still  are  drawn  from  the  wage- 
earning  class,  with  more  or  less  inadequate  early  education. 
The  results  are  that  many  find  the  higher  demands,  edu- 
cational and  mental,  of  institution  work  beyond  their 
capabilities,  and  take  up  private  nursing  as  the  branch 
in  which  they  are  most  likely  to  achieve  success.  A  large 
field  of  peculiarly  interesting  work  is  thus  left  very  par- 
tially developed,  waiting,  in  fact,  for  its  best  development 
until  a  larger  portion  of  the  educated  women  of  America 
recognize  in  hospital  work  a  scope  for  their  talents  and 
energies. 

An  impetus  has  been  given  in  recent  years  in  this  direc- 
tion by  the  establishment,  in  Columbia  University,  of  a 
chair  of  domestic  science,  and  the  appointment,  as  its 
head,  of  a  trained  nurse,  the  former  superintendent  of  one 
of  the  first  training-schools  for  nurses  in  America.  The 
establishment,  too,  of  a  special  course  in  hospital  eco- 
nomics in  the  same  university  some  twelve  years  ago  was 
one  of  the  early  indications  that  nursing  was  departing 
from  the  amateur  methods  of  the  "  vocation  "  or  "  call- 
ing "  and  receiving  recognition  as  a  profession,  with  educa- 
tional requirements  and  professional  aims.  To  those  who 
really  love  the  work  nursing  will,  however,  always  largely 
appeal  as  a  vocation,  just  as  whatever  the  professional  or 
scientific  interest,  his  actual  work  with  humanity  in- 
variably appeals  to  a  certain  type  of  doctor. 

THE   SCHOOL    COURSE 

The  instruction  given  to  a  pupil  may  be  considered 
under  two  heads,  practical  and  theoretic,  that  taught 
at  the  patient's  bedside  and  that  studied  in  text-books. 

Theoretic  Instruction. — In  the  theoretic  work,  the  sub- 
jects considered  essential  have  already  been  enumerated. 
Elementary  anatomy  and  physiology,  elementary  medi- 
cine and  surgery  in  their  relation  to  nursing,  including 
such  special  branches  as  contagious  diseases,  disease  in 
children,  gynecology  and  obstetrics,  food  values  and  diet, 


THE   SCHOOL   COURSE  45 

cooking,  hygiene,  elementary  materia  medica,  and  ele- 
mentary bacteriology. 

It  is  necessary  to  preface  the  subjects  in  most  instances 
by  the  word  elementary,  a  decided  handicap  in  teaching 
a  subject.  The  field  of  instruction  in  each  subject  is 
prescribed,  but  in  such  a  manner  that  in  many  instances 
the  term  "  special  "  more  accurately  describes  it  than 
"  elementary,"  which  is  too  often  synonymous  with 
superficial.  What  has  to  be  taught  has  to  be  thoroughly 
and  accurately  mastered,  and  will  generally  combine 
with  elementary  facts  those  facts  and  theories  revealed 
by  the  latest  research,  as,  for  instance,  in  the  study  of 
medicine,  surgery,  or  bacteriology.  This  condition  brings 
about  a  peculiar  difficulty  in  arranging  the  theoretic 
instruction  of  nurses.  On  few  subjects  are  adequate 
text-books  written  from  which  classes  of  nurses  can  be 
taught  without  the  intervention  of  special  lectures,  spe- 
cially prepared  for  the  individual  class. 

On  elementary  anatomy  and  physiology  there  are 
several  sound  text-books,  conveying  in  book  form  the 
practical  knowledge  necessary  to  a  nurse  on  this  subject. 
In  materia  medica  also  the  subject  has  been  adapted  by 
several  authors  to  the  requirements  of  a  nurse's  curriculum; 
the  latter  are,  however,  reference  books,  and  could  not,  as 
could  the  books  on  anatomy  and  physiology,  be  used  in 
class  except  in  combination  with  a  specially  prepared 
course. 

Lecturers. — The  issue  of  such  lack  of  adequate  teaching 
material  is  that  the  schools  have  to  depend  for  their  in- 
struction almost  entirely  on  the  lecture  system.  This  entails 
a  special  lecturer  for  each  subject,  who  must,  besides  teach- 
ing, decide,  first  of  all,  what  in  his  subject  are  the  points 
necessary  for  a  nurse  to  study.  In  a  small  hospital 
the  special  lecturer  is  a  difficult  matter  to  attain,  and  in 
many  instances  the  lectures  are  given  either  by  those  not 
specially  experienced  in  teaching,  or  by  those  whose 
teaching  of  the  subject  has  been  on  the  lines  required  by 
advanced  medical  students,  and  who  find  difficulty  in 
adapting  their  lectures  to  the  requirements  of  the  pupil 
nurse.  The  pupil  has  then  to  study  her  subjects  from 


46  INTRODUCTION 

her  notes,  taken  at  lecture,  with  the  help  of  text-books 
or  manuals  written  for  the  medical  student  or  the  prac- 
titioner. 

It  must  be  remembered  that  the  average  pupil  nurse 
comes  with  a  grammar-school  education,  sometimes  with 
a  high-school  education,  but  rarely,  indeed,  after  a  college 
course.  Her  work  there  is  for  the  first  time  presented  to 
her  entirely  in  the  form  of  lectures,  instead  of  the  recitation 
system  with  which  she  is  familiar.  A  study  of  the  note- 
book of  the  average  nurse  shows  one  what  an  added  stumb- 
ling-block in  her  work  the  lecture  system  is.  It  has  educa- 
tional value  only  when  it  is  possible  to  supplement  the 
lecture  with  one  or  more  classes  on  each  lecture,  one  of 
which  will  be  taken  up  with  elucidating  and  straighten- 
ing out  the  pupil's  notes.  In  other  words,  two  must  do 
what  one  could  accomplish  by  the  system  of  lesson-books 
and  recitations. 

The  practical  fact,  too,  must  not  be  overlooked  that 
to  the  pupil  engaged  in  the  exacting  and  fatiguing  duties 
of  nursing  for  an  average  of  eight  or  nine  hours  a  day,  the 
theoretic  work  is  a  part  of  her  education  to  which  she  not 
infrequently  brings  tired  brains  and  overworked  nerves. 
The  conditions  under  which  she  must  study  are,  therefore, 
hard,  and  the  studies  should  be  made  as  simple  of  assimila- 
tion as  is  compatible  with  thoroughness. 

In  many  schools  the  lecturers  are  voluntary  workers,  a 
regretable  condition  frequently  implying  amateur  work 
irregularly  performed.  In  the  better  schools,  however,  the 
lecturers  are  properly  salaried  by  the  training-school,  and 
in  these  cases  the  work  given  is  generally  of  a  higher 
order. 

Order  of  Studies. — To  dictate  an  order  in  which  these 
studies  should  be  taken  up  is  not  possible:  the  educational 
work  of  a  training-school  is  necessarily  governed  by  the 
practical  requirements  of  the  daily  work.  For  example, 
where  the  hours  on  duty  are  short  and  the  number  of 
pupils  is  sufficiently  large  for  an  entire  class  to  be  collected 
together  from  ward  duty  at  given  hours  during  the  day, 
two  or  even  more  subjects  may  be  studied  simultaneously. 
When  the  only  hour  for  lecture,  class,  or  private  study  is 


THE    SCHOOL   COURSE  47 

in  the  evening,  after  a  long  day's  work,  it  is  almost  im- 
possible to  do  more  than  take  each  subject  in  turn. 

It  may  be  conceded,  however,  that  the  subjects  of 
medical  and  surgical  nursing,  general  and  special,  are 
more  intelligently  studied  when  the  pupils  have  become 
familiarized  with  the  symptoms  and  signs  of  disease,  and 
when  reference  can  be  made,  and  examples  cited,  from  the 
practical  work  on  which  the  pupils  are  at  the  time  engaged. 
One  would  place  such  subjects  then  in  the  second  and 
third  year,  and  the  subjects  that  are  studied  chiefly  in  the 
class-room  in  the  first  year. 

Food  values,  the  nature  and  action  of  the  most  com- 
monly used  drugs,  the  theories  of  infection  and  principles 
of  asepsis,  should  always  be  taught  to  a  nurse  at  an  early 
stage  in  her  training.  Where,  from  some  such  conditions 
as  just  indicated,  some  or  all  of  these  subjects  are  left  until 
the  second  or  third  year,  some  lessons  on  each  should  be 
given  during  the  first  months  to  the  class,  and  can  be 
elaborated  on  later  on.  They  bear  too  distinctly  on  the 
work  in  hand  to  be  omitted. 

Elementary  anatomy  and  physiology  are  usually  taught 
in  the  first  year,  a  custom  which  has  practical  advantage. 
The  subject  is  the  necessary  foundation  and  framework 
of  much  that  is  to  follow,  and  being  itself  a  very  definite 
study,  dissociated  from  theory  or  imaginings,  has  decided 
educational  value.  In  conjunction  with  this  study  the 
pupils  may  be  taught  right  methods  of  note-taking  and  to 
form  regular  habits  of  study.  As  it  is  a  subject  studied 
entirely  in  the  class-room,  and  not  really  helped  by  the 
practical  work,  it  often  appears  from  cursory  observation 
that  a  larger  amount  of  time  is  spent  over  this  study  in 
proportion  to  any  one  other  subject.  It  must,  however, 
be  borne  in  mind  that  on  all  the  other  subjects  the  pupil 
is  receiving  practical  instruction  daily  with  one  or  other 
detail  of  her  work. 

Where  practical,  the  pupil  is  probably  most  helped  in 
her  work  by  some  such  division  of  subjects  as  the  follow- 
ing. In  the  first  year  elementary  anatomy  and  physiology, 
with  special  short  courses  of  four  or  six  lessons  each  in 
elementary  bacteriology,  food  values,  and  materia  medica, 


48  INTRODUCTION 

the  latter  including  uses,  action,  and  dosage  of  the  prin- 
cipally used  drugs. 

In  the  second  and  third  year  the  subjects  of  medical  and 
surgical  nursing  and  obstetrics  must  be  studied,  and  bac- 
teriology, materia  medica,  and  dietetics  elaborated,  and 
short  but  thorough  courses  on  the  later  subjects  given  in 
turn.  Where  the  hours  of  work  permit,  an  extra  subject 
to  be  thoroughly  taken  up  in  the  first  year, — probably 
the  most  valuable  is  dietetics, — including  the  practical 
work,  invalid  cooking,  and  the  compiling  of  different 
diets. 

In  thus  reviewing  the  subjects  one  sees  clearly  the 
enormous  saving  it  would  be  to  the  pupil  to  have  mastered 
the  subjects,  except  those  of  medical  and  surgical  nursing, 
before  beginning  her  absorbing  and  fatiguing  practical 
work — work,  it  must  be  remembered  on  which  the  ex- 
action of  modern  medicine  and  surgery  are  constantly  lay- 
ing heavier  burdens.  When  schools  are  able  to  afford  a 
prolonged  preliminary  course  for  their  probationers,  this  is 
in  a  measure  accomplished.  Comparatively  few,  however, 
are  the  schools  that  are  in  position  to  incur  the  expense 
of  boarding,  lodging,  and  instructing  a  class  of  students 
who  pay  no  fees  and  do  not  share  in  the  work  of  the 
hospital. 

Central  Preparatory  Schools. — It  would  seem  as  though 
the  time  had  come  for  the  establishment  of  central  pre- 
paratory schools  for  hospital  nurses,  where  all  preliminary 
teaching  can  be  adequately  carried  out  before  the  full 
demands  of  the  practical  work  of  nursing  are  incurred. 
An  attempt  in  this  direction  has  been  made  by  several 
institutions,  especially  the  Drexel  Institute  in  Philadel- 
phia, and  Simmons  College,  Boston.  The  course  is  recog- 
nized in  some  of  the  leading  training-schools,  and  pupils 
who  have  taken  it  are  permitted  a  somewhat  shorter 
period  in  the  training-school  (usually  four  to  six  months 
is  allowed),  and  are  exempt  from  further  instruction  in 
the  subjects  already  studied.  The  ideal  method,  however, 
would  be  a  residential  school,  with  all  instruction,  study, 
and  educational  methods  applied  directly  with  a  view  to 
their  value  and  bearing  on  the  subject  of  nursing. 


THE   SCHOOL  COURSE  49 

Examinations. — Where  teaching  is  perfect,  examina- 
tions are  unnecessary.  It  may  be  taken,  however,  that 
the  ideal  is  unattainable,  and  that  however  unsatisfactory 
the  system  of  competitive  examination,  it  is,  nevertheless, 
a  legitimate  test  of  the  knowledge  and  industry  of  an 
average  class.  A  word  may  be  said  as  to  the  importance 
of  making  the  oral  examination  as  fair  a  test  as  the  written 
one.  In  the  written  examination  one  or  at  most  two  sets 
of  questions  are  given  to  the  entire  class ;  in  the  oral,  too 
often,  the  examiner  takes  no  trouble  to  prepare  his  ques- 
tions beforehand,  and  the  result  is  a  separate  set  of 
questions  for  each  pupil  quite  unequal  in  value.  In 
fairness  the  oral  questions  should  be  thought  out  with 
the  same  care  as  the  written  examination,  written  down 
beforehand,  and  the  pupils  submitted  to  equal  tests. 
A  good  teacher  is  rare,  but  a  good  examiner  is  rarer 
still. 

If  the  instruction  is  given  by  the  lecture  system,  the 
lectures  should  be  supplemented  by  classes  and  frequent 
oral  and  written  exercises  on  the  subject,  always  bearing 
in  mind  that  the  average  educational  standing  of  the 
pupil  nurse  is  low  and  her  capacity  for  independent 
study  limited,  and  that,  owing  to  the  arduousness  of  her 
duties,  she  never  comes  fresh  to  her  book  work.  More 
help  is  required  from  tuition,  therefore,  than  in  other 
circumstances  if  the  work  is  to  be  of  honest  and  help- 
ful quality,  and  will  require  to  be  methodically  and  sys- 
tematically given. 

Practical  Instruction. — No  department  of  a  nurse's 
education  can  be  considered  as  important  as  her  thorough 
instruction  in  practical  methods.  It  is  essentially  what 
she  comes  to  a  hospital  to  learn,  and  something  she  cannot 
pick  up  from  books  or  lectures. 

As  has  already  been  touched  upon,  we  have  two  meth- 
ods of  teaching  in  vogue  at  present:  teaching  in  classes, 
before  the  pupils  are  placed  in  the  wards,  and  placing  each 
probationer  directly  in  the  ward  as  soon  as  she  enters  the 
training-school.  The  disadvantages  of  the  later  system 
have  already  been  pointed  out;  real  systematic  instruc- 
tion is  almost  impossible. 
4 


50  INTRODUCTION 

The  variety  of  methods  of  teaching  in  classes  are  numer- 
ous and  governed  by  the  necessities  of  the  hospital  work 
which  cannot  be  put  on  one  side  to  carry  out  a  system. 
In  many  instances  a  compromise  is  made,  and  while  the 
probationers  do  regular  duty  in  the  wards,  they  are  col- 
lected together  for  some  period  every  day,  and  the  proper 
methods  of  doing  their  work  demonstrated  in  the  class- 
room and  practised  under  supervision.  A  good  text-book 
on  practical  methods  of  nursing  should  be  used  both  for 
reference  and  to  establish  uniformity  of  methods. 

Where  the  financial  resources  of  the  school  permit, 
a  preliminary  course,  usually  of  six  months'  duration, 
is  given,  during  which  time  the  pupils  receive,  besides 
practical  instruction  in  methods  of  nursing,  a  full  course 
on  dietetics,  with  practical  instruction  in  invalid  cooking, 
and  lectures  and  classes  on  elementary  anatomy  and 
physiology,  materia  medica,  bacteriology,  hygiene,  and 
principles  of  nursing. 

During  this  time  they  do  either  no  actual  nursing  in  the 
wards  or  a  very  limited  amount. 

Comparatively  few  hospitals  are  in  a  position  to  estab- 
lish a  full  preliminary  course;  usually  the  exigencies  of 
the  work  demand  that  the  probationers  take  their  share 
of  the  nursing. 

One  method  by  which  the  probationers  may  benefit 
by  special  instruction  and  at  the  same  time  share  in  the 
work  of  nursing  is  to  take  one  or  two  wards,  and,  assisted 
by  demonstration  in  the  class-room,  teach  the  practical 
nursing  at  the  patient's  bedside.  A  woman's  medical  and 
a  woman's  surgical  ward  are  the  most  suitable  for  such  in- 
struction, though,  as  the  pupils  become  accustomed  to  the 
routine  work  of  nursing,  they  can  be  dispersed  among  the 
other  wards  at  given  hours.  Three  hours'  ward  work  in 
the  morning  and  a  couple  of  hours  in  the  evening  can  be 
spent  daily  entirely  over  practical  details,  and  always 
under  the  supervision  of  the  special  instructress  of  the 
preliminary  class.  She  accompanies  her  pupils  to  the 
wards,  and  is  directly  responsible  for  seeing  that  the  work 
is  efficiently  carried  out.  In  a  short  time  the  preliminary 
class  is  able  to  do  all  the  routine  work  of  bed-making, 


THE   SCHOOL   COURSE  51 

washings,  and  so  forth  in  the  wards  assigned  for  the 
special  instruction,  while  sufficient  time  is  left  for  teaching 
in  turn  all  practical  methods. 

As  the  morning  and  evening  routine  work  in  most 
hospitals  is  somewhat  similar,  a  time-table,  somewhat  as 
follows,  is  suggested,  and  has,  it  may  be  added,  been  found 
practicable: 

7-10  A.  M.:        Wards;  routine  work  and  demonstration. 
10-10.40  A.  M.:  Domestic  work  (cleaning  utensils,  bath-tubs,  dust- 
ing, etc.). 

10.40A.M.:        Lunch  and  change  aprons. 
11-12  M.:  Class  or  class-room  demonstration. 

12-1  P.  M.  Recreation  and  luncheon. 

1-2  P.  M.  Study,  each  pupil  in  her  own  room. 

2-4  p.  M.  Recreation  out-of-doors. 

4-6  P.  M.  Wards;  routine  work  and  demonstration. 

6-7  P.  M.  Preparation   of   surgical    supplies,  which  is  not 

fatiguing  work,  and  can  be  performed  sitting 
down. 


The  last  hour  is  also  used  once  a  week  for  lecture.  At 
seven  the  pupils  dine.  No  work  is  done  afterward,  nor 
if  the  class  work  and  study  hour  are  honestly  employed 
is  it  usually  necessary  for  the  probationer  pupil  to  study 
in  the  evening.  The  subjects  for  study  are  elementary 
anatomy  and  physiology  and  the  principles  and  practice 
of  nursing.  The  latter  subject  is  stretched  to  include 
some  lessons  in  elementary  materia  medica  and  bacteriol- 
ogy in  their  relation  to  nursing,  and  food  values,  with 
some  practical  instruction  in  the  simpler  forms  of  invalid 
cooking. 

In  three  months  a  very  large  field  of  practical  nursing 
can  be  intelligently  covered.  Besides  the  fresh  work 
taught  each  week,  care  must  be  taken  that  opportunity 
is  afforded  for  sufficient  practice  in  the  work  already 
taught.  Where  access  can  be  had  to  a  surgical  out- 
patient department,  some  of  the  pupils  can  be  taken  in 
turn  from  the  ward  work,  and  receive  instead  instruction 
in  minor  dressings  and  bandaging. 

The  following  schedule  is  suggested  as  conveniently 
grading  the  instruction,  and  has  been  proved  practical  in 
carrying  out: 


52  INTRODUCTION 

First  Week. 

Bed-making,  washing,  care  of  backs,  care  of  bath-rooms, 
utensils,  etc.,  dusting. 

Second  Week. 

Admission  of  new  patients,  care  of  their  effects,  tub- 
baths,  taking  of  temperature,  pulse,  and  respiration. 

Third   Week. 

Enemata,  simple,  purgative,  and  medicated,  enterocly- 
sis,  douche,  tampon. 

Fourth   Week. 

Medicines  and  medicine  giving;  temperature  chart; 
preparation  of  special  diets  and  drinks;  milk,  pasteurize 
and  modify. 

Fifth   Week. 

Poultice,  mustard  plaster,  stupe,  compress,  ice-bag, 
hot-water  bag,  cupping,  inunction,  cautery,  blister,  sur- 
gical dressing. 

Sixth   Week. 

Care  of  typhoid  patient,  disinfection  of  linen,  etc., 
sponging,  Brandt  bath,  cradling,  cold  pack,  ice  rub, 
sprinkling. 

Seventh   Week. 

Care  of  special  cases  (each  pupil  to  have  charge  of  one 
case);  special  chart;  female  catheter. 

Eighth   Week. 

Preparation  of  patient  for  operation;  preparation  of 
field  of  operation  for  section,  limb,  plastic,  head  and  eye: 
care  of  patient  in  anesthetic  room. 

Ninth   Week. 

After-care  of  operation  cases;  diet,  lavage,  hypodermo- 
clysis,  preparation  for  intravenous  infusion,  treatment  of 
hemorrhage. 


THE   SCHOOL   COURSE  53 

Tenth   Week. 

Hot-air  baths,  hot  packs,  sweat-baths,  diet  and  drugs  to 
induce  sweating,  medicated  tub-baths,  special  points  in 
nursing  affections  of  eye  and  ear. 

Eleventh   Week. 

Children's  nursing,  special  points  in  enteritis,  menin- 
gitis, pneumonia,  infantile  paralysis,  and  orthopedic 
cases,  diet,  infant's  foods,  use  of  battery  and  oxygen  ap- 
paratus. 

Twelfth  and    Thirteenth   Weeks. 

Amphitheater;  prepare  for  operation  and  clean  up  after; 
care  of  patient  throughout. 

For  the  last  two  weeks'  work  in  the  amphitheater  it 
will  be  necessary  to  take  the  pupils  in  turn  and  to  place 
them  under  the  head  nurse  in  the  amphitheater.  Two 
weeks  may  be  taken  from  the  last  half  of  the  preliminary 
course  and  made  up  on  return,  or  the  pupils  may  be 
placed  in  the  wards  at  the  end  of  the  eleventh  week  and 
taken  in  turn  from  the  wards. 

The  class  work  should  be  carried  on  side  by  side  with 
the  practical  work  on  hand  in  the  wards. 

One  advantage  of  this  system  of  ward  teaching  is  that 
from  the  beginning  the  pupils  are  in  contact  with  the 
patients,  and  working  in  the  surroundings  proper  to  their 
work.  From  the  beginning  they  can  be  taught  to  comport 
themselves  with  quietness,  reserve,  and  discretion  in  the 
wards,  and  to  cultivate  habits  of  courtesy,  kindness,  and 
patience  toward  those  they  nurse.  To  start  a  class  with 
good  ideals  in  these  respects  is  infinitely  easier  than  to 
inculcate  them  when  the  pupils  are  scattered  through 
various  wards  and  plunged  straight  into  the  rush  of  work. 

Domestic  Training. — A  constantly  vexed  question  is 
concerned  with  how  much  or  how  little  housework,  gener- 
ally spoken  of  as  menial  work,  should  be  required  of  a 
nurse.  Our  traditions  of  work  come  from  a  time  when  all 
services  to  the  sick  in  the  most  remote  way  for  his  comfort 
ranked  the  same  and  were  carried  out  in  a  spirit  of  religious 
devotion  which  glorified  the  humblest  act.  We  may 


54  INTRODUCTION 

take,  as  a  poignant  example  of  such  devotion,  the  action  of 
the  good  Sisters  of  Paris,  who,  in  the  bitterest  winter 
weather,  broke  the  ice  of  the  Seine  and  washed  their  pa- 
tients' bed-linen  in  the  icy  waters  ("  History  of  Nursing," 
M.  A.  Nutting  and  L.  L.  Dock).  But  these  traditions  are 
crossed  by  a  darker  time  when  no  services  but  the  most 
menial  and  the  simplest  could  have  been  exacted  from  the 
degraded  women  who  alone,  for  more  than  a  century,  cared 
for  the  sick  in  the  public  hospitals  of  Protestant  countries. 
Such  services  were  almost  the  chief  raison  d'etre  of  the 
sick  nurse  at  the  time  when,  as  an  outcome  of  the  heroic 
work  done  by  Florence  Nightingale  and  her  band  of  work- 
ers in  the  Crimea,  the  early  training-schools  for  nurses 
were  established  in  a  few  of  the  English  hospitals.  What 
these  early  devoted  pioneers  of  nursing  required  above  all 
things  was  opportunity  to  work  and  study  in  the  hospitals, 
and  by  making  their  services  indispensable,  to  open  the 
way  for  future  generations  of  workers;  it  was  no  time  to 
pick  and  choose  among  the  various  duties  expected  from  a 
nurse;  to  say  we  will  do  this,  but  for  the  other  you  must  get 
in  a  second  staff  of  women  and  pay  them  to  do  it,  even 
had  not  the  example  of  the  sisterhoods  probably  influenced 
the  secular  workers  to  embrace  the  humbler  services  in 
a  spirit  of  devotion  and  self-abnegation.  Few  hospital 
boards,  and  few  doctors,  welcomed  with  any  enthusiasm 
the  advent  of  the  "lady  probationer,"  as  she  was  quaintly 
called,  in  the  hospital  wards.  She  had  to  prove  her  utility 
before  she  was  in  a  position  to  make  terms.  Cooking, 
laundry  work,  window-cleaning,  and  the  scrubbing  of  the 
long  wards  and  corridors  were  not  required  of  her,  but  all 
other  services  of  a  domestic  economy,  sweeping,  dusting, 
cleaning,  washing  dishes  and  cleaning  knives,  attending  to 
the  huge  grates  of  soft  coal,  fetching  and  carrying  drug 
supplies,  coal  buckets,  and  milk  cans  (there  were  no  ele- 
vators), had  all  been  the  work  of  the  assistant  nurse  whose 
place  she  now  practically  took.  It  is  hardly  too  much  to 
say  she  brought  the  domestic  work  of  a  hospital  to  a  pitch 
of  perfection  that  was  really  an  art,  and  turned  the  dreary 
wards  of  a  public  hospital  into  a  picture  of  comfort  and' 
beauty. 


THE    SCHOOL  COURSE  55 

To  at  all  realize  what  she  has  done  one  must  go  from 
one  or  other  of  our  modern  hospitals  to  a  secular  hospital 
in  some  of  the  large  European  cities,  where  trained  nursing 
is  still  unknown.  The  lack  of  common  cleanliness,  of 
decency,  of  comfort,  to  be  found  existing  side  by  side 
with  the  most  advanced  methods  of  modern  medicine 
and  surgery,  speaks  volumes  for  what  the  modern  nurse  has 
already  accomplished. 

At  the  present  day  every  hospital  has,  besides  the  cooks 
and  cleaners,  a  staff  of  servants  to  perform  the  heavier 
duties  of  its  domestic  work.  Why,  then,  it  is  frequently 
asked,  need  any  such  services  be  part  of  a  nurse's  train- 
ing? It  is  claimed  that  the  nurse  is  by  these  duties  un- 
necessarily fatigued;  that  it  wastes  her  time,  and  takes 
her  away  from  the  patient,  when  she  cannot  be  replaced, 
to  do  duties  which  can  easily  be  achieved  by  unskilled 
labor. 

The  domestic  duties  of  a  nurse  at  the  present  day 
usually  consist  in  dusting  and  cleaning  the  ward  furniture, 
cleaning  and  keeping  clean  all  vessels,  utensils,  implements, 
and  appliances  used  by  the  patients,  and  the  keeping  in 
proper  order  of  her  store  closets,  linen  cupboards,  refriger- 
ators, and  so  forth.  The  cleaning  usually  includes  care 
of  the  bath-tubs  and  wash-basins,  and  the  polishing  of 
the  spigots  attached  to  them.  Her  duties  have  been 
immensely  lightened  by  the  introduction  of  nickel  plate 
instead  of  brass,  agate  and  enamelware  instead  of  metal 
for  bowls  and  dressing  basins,  and  rubber  instead  of  metal 
for  hot-water  cans,  douche  cans,  etc.  From  the  point 
of  physical  fatigue  the  duties  are  not  heavy,  and  in  a 
properly  organized  ward,  where  the  duties  are  carefully 
divided  (see  Ward  Management),  probably  one  hour  or 
an  hour  and  a  half  daily  is  the  utmost  that  any  nurse  spends 
in  duties  not  directly  connected  with  the  patients,  and 
the  more  skilled  nurses  not  anything  like  as  much. 

To  dust  and  polish  is  no  greater  strain  on  the  muscles 
than  the  gymnastics  or  swimming-pool  urged  at  the  pres- 
ent day  as  appropriate  recreations  for  the  pupil  nurse, 
and  if  they  cannot  be  classed  as  recreations,  I  think  most 
nurses  have  found  them,  in  their  hours  on  duty,  a  distinct 


56  INTRODUCTION 

relaxation  from  the  unconscious  mental  strain  implied 
by  close  attention  on  the  patients  themselves. 

The  gain  to  the  pupil  herself  is  real.  For  probably  the 
first  time  in  her  life  she  is  taught  efficient,  economic,  and 
time-saving  methods  of  doing  domestic  work;  principles 
of  economy  are  forced  upon  her  attention.  She  sees  demon- 
strated that  thought  and  method  applied  to  such  work 
lessen  their  burden,  and  that  care  in  handling  will  prolong 
enormously  the  life  of  the  most  perishable  equipment. 
The  gain  to  the  institution  is  also  practically  economic. 
The  pupils  of  to-day  are  the  superintendents  of  to-morrow, 
and  a  superintendent  trained  by  this  system  brings  to 
the  institution  she  serves  a  practical  knowledge  of  domestic 
management  and  standards  of  efficiency  and  economy 
quite  invaluable.  From  this  point  of  view  alone  we  should, 
were  we  compelled  to  drop  all  "  domestic  work  "  from 
a  nurse's  training,  probably  be  obliged  to  supplement  it 
with  an  expensive  and  not  wholly  adequate  course  in 
"  domestic  science  "  at  some  industrial  institution. 

For  private  nursing  such  training  is  certainly  a  neces- 
sity, the  care  of  the  sick-room  being  in  most  instances  a 
necessary  part  of  the  duties  of  a  private  nurse.  Except 
in  the  houses  of  the  very  wealthy,  sickness  taxes  seriously 
the  resources  of  the  household :  it  is  no  time  to  exact  extra 
duties  from  the  already  upset  domestics.  Frequently 
also  it  is  undesirable  that  any  but  the  nurse  should  be 
admitted  to  the  patient's  room,  and  it  is  always  desirable 
that  all  work  about  a  patient  should  be  done  to  perfection. 
It  will  not  be  so  done  unless  the  nurse  has  been  trained 
to  consider  such  her  duties,  and  required  to  perfect  herself 
in  their  performance. 

A  further  point  in  the  favor  of  some  domestic  duties 
is  that  they  are  of  value,  indeed,  almost  indispensable, 
in  teaching  habits  of  thoroughness,  energy,  deftness,  and 
quickness,  all  necessary  in  efficient  nursing,  but  very 
difficult  to  enforce  if  the  actual  care  of  the  sick  patient  is 
our  only  training-ground.  Quickness  may  be  taught  by 
apportioning  a  set  time  to  be  spent  over  certain  tasks  and 
finishing  punctually;  the  brightness  of  copper  or  brass 
speaks  for  itself  of  energy  or  inefficiency;  in  the  dusting 


THE   SCHOOL   COURSE  57 

of  a  ward  a  great  deal  of  deftness  is  learned,  and  the  habit 
of  going  quietly  and  swiftly  about  one's  business.  These 
matters  can  often  not  be  taught  over  the  patient.  For  ex- 
ample, a  pupil  can  hardly  be  directed  to  be  quick  over  a 
patient  without  leaving  him  with  a  sense  that  other  matters 
are  considered  of  more  importance  than  his  welfare,  and 
yet  if  all  are  to  have  their  due  attention,  quickness  that 
is  not  hurry  is  a  real  essential  in  a  busy  ward. 

A  well-known  surgeon,  entirely  in  sympathy  with  the 
broadest  aims  of  a  nurse's  education,  once  told  me  that 
he  considered  the  movements  required  for  polishing  and 
so  forth  an  invaluable  education  for  the  nurse's  hands,  and 
if  he  could  he  would  put  all  surgical  students  through 
some  such  course,  in  order  to  train  them  in  manual  skill 
and  deftness.  It  seems  a  point  worth  recognizing. 

The  different  processes  of  cleaning  should  be  as  care- 
fully taught  and  as  closely  supervised  as  any  other  part 
of  a  nurse's  practical  work,  and  particular  emphasis 
should  be  laid  on  the  following  points — punctuality  in 
beginning  work,  quickness  in  finishing,  thoroughness  in 
accomplishing,  economy  in  using  supplies,  care  in  handling 
equipment,  method  in  planning  work,  and  quietness  and 
dignity  in  carrying  it  out.  Experience  shows  that  a 
thorough  grounding  only  will  produce  efficiency,  and 
that,  unless  a  genuine  interest  is  taken  in  its  proper  per- 
formance, the  domestic  details  of  her  work  are  considered 
by  the  average  nurse  as  beneath  her  dignity,  and  done  in 
a  slovenly,  inadequate  manner.  Teach  her  properly, 
and  train  her  to  realize  that  cleanliness  is  economy,  that 
it  directly  affects  the  mental  condition  of  her  patients, 
and  that  it  is,  moreover,  one  of  the  most  powerful  pro- 
phylactics against  disease,  and  the  domestic  details  of  her 
work  assume  a  different  aspect. 

At  the  end  of  three  months  of  such  a  course  as  outlined 
the  pupils  enter  the  different  wards  for  a  further  three 
months  of  probation.  An  effort  should  be  made  to  con- 
tinue the  class  work  daily,  and  such  practical  subjects  as 
bandaging,  the  dressing  of  surgical  cases,  and  the  keeping 
of  charts  may  be  more  thoroughly  taught  and  practised, 
while  written  quizzes  and  papers  on  practical  subjects 


58  INTRODUCTION 

may  be  required  from  time  to  time.  At  the  end  of  six 
months  the  pupils  are  admitted  to  the  school,  usually  after 
a  written  and  practical  examination  on  the  subjects  studied 
during  the  probation.  The  nurse's  education  is  but  begun, 
but,  it  may  be  conceded,  she  has  been  placed  in  the  best 
conditions  for  her  development  and  given  a  sound  funda- 
mental knowledge  of  the  work  in  the  performance  of  which 
she  expects  to  perfect  herself. 


CHAPTER  I 
PRACTICAL  METHODS 

Beds  and  Bed-making — A  Medical  Bed — A  Surgical  Bed — To 
Turn  a  Sheet — To  Turn  a  Mattress — To  Give  a  Fresh  Mattress — 
Bed-bath— To  Change  the  Shirt— Care  of  the  Mouth— Care  of  the 
Back — Bed-sores— A  Water-bed — To  Give  a  Bed-pan — Care  of  the 
Hair — Treatment  for  Pediculi — Lifting — To  Arrange  a  Patient  Up- 
right in  Bed. 

THE  following  lessons  are  specially  designed  to  be  taught 
to  the  pupils  in  classes :  first,  where  practical,  in  the  demon- 
stration or  class-room,  and,  afterward,  practised  under 
trained  supervision  at  the  patient's  bedside. 

From  the  beginning  the  pupil  should  be  trained  to 
use  her  power  of  intelligent  observation,  probably  her 
most  valuable  practical  quality  as  a  nurse,  and  com- 
monly latent  at  the  beginning  of  her  training.  For 
example,  in  the  simple  matter  of  bed-making  the  pupil 
should  be  directed  to  notice  the  kind  of  bedstead  used, 
the  material  of  which  the  mattress  is  made,  the  quality 
of  the  bed-clothes,  and  the  chief  reasons  for  such  selection 
pointed  out.  When  each  piece  of  work  is  finished,  she 
should  be  taught  to  look  at  it  and  decide  for  herself  it  is 
perfectly  finished  or  in  what  way  defective.  The  habit  of 
mind  so  formed  is  a  solid  gain. 

BEDS  AND   BED-MAKING 

The  essential,  indispensable  part  of  the  equipment  of 
a  sick-room  or  ward  is  the  bed.  It  must  be  comfortable 
for  the  patient,  practical  to  clean  or  disinfect,  and  con- 
venient to  handle. 

The  bed  accepted  as  most  suitable  for  nursing  the  sick 
is  a  single  bed,  made  of  enameled  iron,  with  a  wire  spring 
mattress,  and  specially  constructed  to  be  easily  taken  apart 
and  put  together;  the  advantages  are  that  they  are  light 
to  move,  easy  to  clean  and  disinfect,  and  do  not  harbor 

59 


60  PRACTICAL   METHODS 

dirt  or  insects,  as  did  the  older  wooden  bedsteads.  A  height 
of  from  24  to  27  inches  from  the  ground  to  the  wire  mat- 
tress is  an  immense  help  to  either  doctor  or  nurse  in  carry- 
ing out  the  offices  and  treatment  required,  and  not  gener- 
ally objected  to  by  the  patient.  The  bedstead  is  usually 
6  feet  4  inches  long  by  3.  feet  wide. 

Wooden  bedsteads,  although  not  unknown  in  hospital 
work,  are  not  infrequently  met  with  in  the  homes  of 
private  patients.  After  any  case  of  illness  such  a  bedstead 
should  be  taken  apart  and  subjected  to  thorough  scrub- 
bing and  disinfection  (see  Disinfectants},  and  when  prac- 
tical, set  in  the  sun,  out-of-doors,  for  some  hours.  If 
animal  life  is  discovered,  the  fumes  of  sulphur  will  kill 
the  animals  better  than  any  other  disinfectant,  but 
nothing  has  yet  been  found  to  destroy  the  eggs.  A  wooden 
bedstead  that  is  really  infested  with  bed-bugs  cannot  be 
saved,  and,  when  practical,  should  be  burned. 

Mattresses. — Mattresses  are  made  of  hair,  cotton,  feath- 
ers, fiber,  or  straw,  and  usually  covered  with  stout  linen  tick- 
ing. Cotton  ticking  may  be  used,  but  is  neither  so  cool  nor 
so  durable.  Straw  can  never  be  described  as  a  comforta- 
ble bed,  but  has  an  advantage  that,  being  inexpensive,  it 
can  be  destroyed  and  renewed  with  each  case,  the  cover- 
ing ticking  being  washed  as  regularly  as  the  bed-clothes. 
For  this  reason  its  use  is  sometimes  advocated  in  epidem- 
ics of  serious  infections,  such  as  small-pox.  In  the  form 
of  a  palliass,  a  stiff  mattress  of  closely  packed  straw,  it 
is  frequently  used  under  a  top  mattress  when  it  is  required, 
as  in  fracture  of  a  thigh,  to  use  a  mattress  that  will  not  sag. 

The  mattress  of  palm  fiber,  or  of  palm  fiber  mixed  with 
hair,  is  less  expensive  than  that  altogether  of  hair,  and  if 
well  made,  is  not  uncomfortable  and  wears  well. 

The  cotton  mattress  is  also  comfortable  until  beginning 
to  wear,  when  it  gets  lumpy.  Its  disadvantages  are  that 
it  is  hotter  than  hair,  considerably  heavier,  and  absorbs  and 
retains  any  discharges  which  may  soak  through  the  tick- 
ing. Being  less  expensive  than  hair,  it  is  frequently  used 
in  dormitories,  where  its  disadvantages  are  not  of  practical 
importance. 

The  feather  mattress  is  not  practical  in  the  sick-room 


BEDS   AND   BED-MAKING  01 

on  account  of  its  heat,  its  tendency  to  form  into  hollows 
and  lumps,  and  from  the  fact  that  it  is  very  difficult  and 
often  impossible  to  make  it  comfortable  with  the  patient 
in  bed.  It  is  never  seen  in  a  hospital.  Persons,  however, 
who  are  used  to  a  feather  mattress  find  anything  else 
chilly  and  hard,  and  it  requires  much  tact  and  judgment  to 
introduce  a  more  practical  and  hygienic  form  of  mattress. 
In  old  people  it  may  frequently  be  an  ill  it  is  wise  to  make 
the  best  of.  In  such  a  case  half  the  mattress  can  be  shaken 
up  at  a  time,  and  the  patient  rolled  on  to  the  prepared  half 
while  the  other  is  shaken. 

The  mattress  stuffed  with  horsehair  is  the  most  comfort- 
able, hygienic,  and  cleanly,  and  the  one  in  ordinary  hospital 
and  domestic  use.  That  for  hospital  use  is  made  slightly 
smaller  than  the  spring  mattress,  as  from  frequent  press- 
ing it  spreads  somewhat,  is  usually  four  inches  thick,  and 
weighs  from  20  to  26  pounds,  22  pounds  being  a  usual 
average.  It  is  lighter  and  does  not  soil  so  readily  as  the 
other  varieties,  horsehair  being  non-absorbent. 

All  mattresses  should  be  protected  by  a  washable  cover, 
which  may  be  made  inexpensively  of  stout,  unbleached 
muslin,  and,  well  shrunken  before  making,  fits  the  mattress 
as  a  pillow-cover  does  a  pillow.  By  this  means  the  life 
of  a  mattress  will  be  materially  prolonged. 

In  some  hospitals,  generally  those  devoted  to  maternity 
cases,  the  mattress  is  dispensed  with  altogether.  Instead 
of  the  wire  mattress  or  slats,  a  heavy  piece  of  sack-cloth, 
canvas,  or  ticking  is  laced  with  cord  to  the  four  sides  of 
the  bed-frame.  On  this  is  laid  a  thick  blanket  covered  by 
a  rubber  sheet  and  the  usual  bed-clothes.  It  is  claimed 
that  it  is  comfortable,  cool  in  summer,  economic,  and 
certainly  hygienic,  as  every  part  is  washed  after  each  case. 

Pillows. — Pillows  are  made  of  hair,  feathers,  or  down, 
the  hair  being  useful  to  support  limbs  or  retain  the  patient 
in  a  fixed  position:  they  may  also  be  used  under  a  feather 
pillow  for  the  head.  Down  is  generally  considered  too  ex- 
pensive for  hospital  use  unless  for  small  pillows  for  the 
head  and  for  infants.  The  pillow  in  common  use  is  the 
feather  pillow,  in  size  usually  30  inches  by  20  inches. 
Pillows  should  be  covered  with  linen  ticking  and  not  with 


62  PRACTICAL   METHODS 

cotton,  as  linen  is  perceptibly  cooler  to  lie  upon.  Besides 
the  pillow  for  the  head,  every  ward  should  possess  a  num- 
ber of  small  pillows,  both  of  hair  and  of  feathers,  of  varying 
sizes,  from  8  inches  square  upward,  to  be  used  for  special 
support. 

Where  necessary,  the  mattress  or  pillows  are  protected  by 
rubber  sheeting.  These  should  be  dispensed  with,  how- 
ever, as  soon  as  possible;  not  only  are  they  uncomfortably 
heating,  but  they  favor  a  tendency  to  bed-sores.  In 
the  interests  of  cleanliness  and  economy,  however,  their 
use  is  frequently  unavoidable,  and  care  should  be  taken  to 
see  that  they  are  in  a  proper  condition  to  fulfil  their  pur- 
pose. (See  Ward  Management,  Chap.  XXIV.)  Pin- 
pricks and  cracks  from  careless  folding  make  a  rubber  as 
useless  as  a  bucket  with  a  hole  in  it. 

Bed-clothes. — The  bed-clothes  needed  in  the  sick-room 
are  the  same  as  those  required  in  health,  with  the  addition 
of  the  draw-sheet.  This  is  a  narrow  sheet,  either  single 
or  double,  folded  across  the  bed  under  the  patient's  hips, 
where  naturally  the  greatest  pressure  of  his  weight  is  felt. 
Its  object  is,  by  drawing  it  to  one  side  or  another,  to  enable 
the  sick  person  to  have  a  cool  and  smooth  spot  given  him 
to  lie  on  without  remaking  the  whole  bed.  It  is  made  a 
yard  longer  than  the  width  of  the  bed,  and  tucked  with  the 
larger  portion  under  one  side  of  the  mattress,  in  order  that 
it  can  be  drawn  at  intervals  to  the  other  side.  For  hos- 
pital purposes  a  good  cotton  drill  a  yard  wide  is  very  prac- 
tical. It  is  firm  enough  not  to  get  easily  into  wrinkles,  and 
takes,  in  mangling,  a  smooth  polish  agreeable  to  rest  upon. 
Old  sheets  may  be  used,  but  are  so  soft  as  to  wrinkle 
quickly.  The  habit  of  using  half-soiled  sheets  as  draw- 
sheets  is  not  a  good  one.  The  sheets  are  of  finer  material 
than  the  draw-sheets  and  get  unduly  worn,  besides  fre- 
quently being  stained  in  a  way  that  makes  them  unsightly, 
and  unfit  for  their  own  use. 

Draw-sheets  are  also  of  use  in  protecting  parts  of  the 
bed  in  danger  of  soiling,  as  from  hemorrhage,  surgical 
dressings,  discharging  wounds,  and  so  forth,  their  advantage 
again  being  that  they  can  be  changed  with  little  disturb- 
ance to  the  patient. 


BEDS   AND    BED-MAKING  63 

Where  necessary  for  the  further  protection  of  the  bed, 
a  small  rubber  sheet,  at  least  four  inches  narrower  than  the 
draw-sheet,  can  be  placed  below  the  draw-sheet  above  the 
under  sheet.  It  must  be  sufficiently  long  to  tuck  in 
firmly  on  either  side,  otherwise  it  will  wrinkle  and  become 
a  source  of  discomfort. 

About  the  remainder  of  the  bed-clothes  a  few  details 
must  be  noted.  If  the  bed  is  to  be  smooth,  the  sheets  must 
be  of  sufficient  size  to  tuck  in  firmly  at  the  top  and  bottom 
and  at  the  sides.  A  stout  quality  muslin,  three-quarters 
of  a  yard  wider  than  the  mattress,  should  be  chosen,  and 
well  shrunken  before  making  up.  The  sheet  should  be 
cut  three-quarters  of  a  yard  longer  than  the  mattress, 
and  hemmed  with  a  two-inch  hem  at  one  end  and  a  one-inch 
hem  at  the  other.  If  the  material  is  not  shrunken  before 
the  sheet  is  made,  one  yard  instead  of  three-quarters  of 
a  yard  must  be  allowed. 

The  spread  should  be  washable  and  light.  The  cotton 
spread  manufactured  by  the  Allandale  Company  is  emi- 
nently suitable.  It  is  made  of  stout  white  dimity,  which 
wears  well,  is  both  dainty  and  serviceable,  and  has  the 
advantage  over  the  heavier  and  more  loosely  woven  spreads 
of  not  perceptibly  shrinking.  Though  slightly  dearer  than 
some  other  varieties  to  purchase,  it  is  less  expensive  in 
the  long  run,  as  it  wears  much  better. 

Where  the  blankets  can  be  obtained  entirely  of  wool, 
they  have  the  advantage  of  being  lighter  in  proportion  to 
their  warmth,  and  wearing  better.  For  practical  purposes, 
however,  a  cheaper  variety  of  blanket  meets  all  the  re- 
quirements. The  care  of  the  blankets  is  such  an  import- 
ant part  of  the  economy  of  a  hospital  ward  that  it  will  be 
treated  at  greater  length  in  another  chapter.  (See  Ward 
Management,  Chap.  XXIV.) 

Bed-making. — The  simple  process  of  making  a  bed  may 
be  a  slovenly,  ineffectual  performance,  or,  in  skilful  hands, 
a  real  source  of  healing  and  comfort.  In  teaching  a  class, 
and  for  the  routine  bed-making  of  a  ward,  the  nurses 
should  work  in  pairs;  the  beds  in  this  way  are  made  more 
efficiently  and  quickly,  and  with  considerably  less  fatigue 
on  the  part  of  the  nurses. 


64  PRACTICAL   METHODS 

Standing  opposite  each  other  on  either  side  of  the  bed, 
with  a  chair  placed  at  the  bottom  of  the  bed,  on  which  is 
laid  the  clean  linen  that  will  be  required,  the  lesson  may 
proceed  as  follows: 

First:  Remove  the  upper  clothing,  one  at  a  time,  by 
taking  the  top  and  bottom  corners,  laying  them  together, 
and  folding  neatly;  lay  each  article  over  the  back  of  the 
empty  chair. 

Second:  When  the  top  sheet  is  reached,  loosen  it  all 
round,  slip  the  patient's  bed-socks  or  slippers  over  his 
feet,  put  on  his  wrapper  or  other  suitable  covering,  and 
help  him  out  of  bed. 

Third:  Remove  the  remaining  clothes  in  the  same 
manner.  If  any  are  to  be  replaced  by  clean  linen,  lay 
the  soiled,  tidily  folded,  on  one  side. 

Fourth:  Brush  the  mattress  with  a  whisk-broom  and 
turn  it  top  to  bottom. 

Fifth:  Replace  the  clothes  in  their  order,  thus:  rubber 
sheet,  sheet,  rubber  draw-sheet,  and  draw-sheet,  tucking 
them  all  very  firmly  under  the  mattress;  beat  up  the 
pillows  and  lay  them  in  place. 

Sixth:  Lay  the  upper  clothes,  with  the  exception  of  the 
spread,  in  order  on  the  bed,  turning  back  the  upper  border 
of  the  sheet  over  the  blankets;  the  upper  margin  of  the 
blankets  should  come  just  below  the  pillow;  the  upper 
margin  of  the  sheet  should  reach  to  the  top  of  the  mattress 
before  folding  back.  Do  not  tuck  them  in  until  the  patient 
has  been  put  back  to  bed. 

Seventh:  Return  the  patient  to  bed  and  divest  him,  un- 
der cover  of  the  bed-clothes,  of  slippers  and  wrapper. 

Eighth:  Tuck  the  clothes  in  and  cover  with  the  spread, 
which  is  tucked  firmly  at  the  bottom  of  the  mattress  and 
at  the  top  is  turned  over  the  upper  margin  of  all  the  blan- 
kets, and  in  its  turn  covered  by  the  reversed  border  of 
the  upper  sheet.  (This  helps  to  keep  the  blankets  clean, 
a  cotton  spread  being  a  simpler  thing  to  wash  than  a 
woolen  blanket.)  Adjust  the  corners  of  the  spread  smartly 
and  the  bed  is  made. 

Points  which  have  always  to  be  emphasized  in  teaching 
a  class  are  the  following: 


BEDS    AND    BED-MAKING  DO 

Have  everything  at  hand  before  you  begin. 

See  that  the  temperature  of  the  room  is  sufficiently 
warm. 

Take  care  that  the  patient  is  not  exposed  to  a  draught. 

Do  not  beat  up  pillows  on  the  patient's  bed  while  he  is 
in  it. 

All  folding  must  be  done  at  the  bottom  of  the  bed,  not 
over  the  patient's  face. 

Never  lean  on  a  bed,  jerk  it,  or  touch  it  unnecessarily: 
such  practices  are  always  annoying,  and  in  some  instances, 
such  as,  for  example,  in  rheumatoid  arthritis  and  some 
forms  of  septicemia,  cause  acute  pain. 

It  is  also  never  too  early  in  a  nurse's  training  to  point 
out  the  necessity  of  a  dignified  and  quiet  demeanor,  and 
a  habit  of  consideration  toward  the  patient.  Personal 
topics  should  not  be  discussed  while  at  work. 

When  the  simple  making  of  beds  has  been  mastered  with 
some  proficiency,  the  next  lesson  may  show  the  methods 
of  changing  a  bed  with  a  helpless  patient  in  it.  This  may 
first  be  practised  with  a  dummy,  or  with  one  of  the  pupils 
acting  the  part  of  the  patient  in  the  demonstration  room, 
or  by  using  a  convalescent  patient,  if  one  is  found  who  does 
not  object  to  assisting  at  a  demonstration. 

To  Change  a  Medical  Bed. — First:  Arrange  a  chair  and 
remove  the  top  coverings,  as  in  the  first  lesson:  retain 
the  undermost  blanket  and  untuck  it  and  the  upper  sheet 
all  round;  holding  the  blanket  over  the  patient  by  its 
upper  margin,  slip  the  sheet  out  from  under,  leaving  the 
patient  covered  by  the  blanket. 

Second:  Loosen  the  underclothes  and  remove  the  pil- 
lows (one  is  practical  to  retain  if  preferred). 

Third:  Turn  the  patient  on  one  side,  keeping  the  blanket 
over  him,  one  nurse  supporting  him  by  the  shoulders  and 
pelvis. 

Fourth:  Roll  the  undersheet  and  draw-sheet  from  the 
side  farthest  from  the  patient  to  the  middle  of  the  bed, 
whisk  the  mattress  free  of  dust,  and  straighten  the  rubber 
sheet;  if  it  is  necessary  to  change  it,  roll  in  the  same 
manner  as  the  sheet. 

Fifth:  Prepare  the  clean  sheet  and  draw-sheet  by  roll- 


66 


PRACTICAL   METHODS 


ing  one-half  from  either  side  toward  the  middle;  lay  the 
rolls  by  the  side  of  the  rolled-up  soiled  sheet. 

Sixth:  Unroll  the  sheet  and  draw-sheet  over  the  exposed 
half  of  the  mattress  and  tuck  them  firmly  in,  turn  the 
patient  on  to  the  clean  sheet,  remove  the  soiled  sheets,  and 
unroll  and  adjust  the  other  half  of  the  clean  ones  in  the 
same  way. 

Seventh:  Turn  the  patient  on  his  back  and  lay  the 
upper  sheet  over  him,  not  covering  his  face;  slip  the  cover- 
ing blanket  from  under  the  sheet,  and  finish  the  bed  in 
the  usual  manner  (Fig.  1). 


Fig.  1. — Changing  the  under  sheet,  medical  method. 

This  method  is  known  as  changing  a  medical  bed,  most 
medical  cases  being  able  to  be  turned  on  the  side.  It  is 
also  applicable  to  the  majority  of  surgical  cases.  What  is 
known  as  the  surgical  method  is  employed  where  turning 
on  the  side  is  impracticable,  the  majority  of  cases  which, 
from  one  reason  or  another,  are  forced  to  retain  a  fixed 
position  being  surgical.  It  is  a  somewhat  more  difficult 
method,  and  should  not  be  taught  until  the  pupil  has 
been  given  some  instruction  in  lifting. 


BEDS    AND   BED-MAKING  67 

Instead  of  from  side  to  side,  the  sheets,  by  the  surgical 
method,  are  changed  from  top  to  bottom ;  in  other  respects 
the  process  is  the  same. 

To  Change  a  Surgical  Bed. — After  proceeding  in  the 
usual  manner  until  the  pillows  are  removed  and  the  pa- 
tient covered  with  one  blanket,  the  sheet  is  rolled  from 
the  top  of  the  bed  down  under  the  patient's  head  to  his 
shoulders,  and  the  clean  one,  folded  crosswise,  is  laid 
beside  it  and  the  top  tucked  in,  covering  the  upper  part 
of  the  bed.  Standing  one  on  each  side,  the  nurses  place 
the  hands  nearest  the  head  of  the  bed  under  the  patient's 
shoulders  and  raise  him  sufficiently,  and  no  more,  to 
enable  them  with  their  free  hands  to  roll  the  soiled  and 
the  clean  sheets  under  the  shoulders  to  the  hips.  The 
pelvis  is  then  raised  in  the  same  manner  and  the  limbs 
in  their  turn,  and  the  bed  is  completed  in  the  usual  way. 
When  it  is  necessary  to  keep  a  joint  or  limb  at  absolute 
rest,  a  third  nurse  is  required  to  support  the  limb  and 
keep  it  immovable  during  the  process. 

A  medical  bed  can  and  should  have  its  under  sheet 
removed  and  replaced  or  changed  once  every  day.  For 
cases  such  as  have  just  been  described,  where  immobility 
is  part  of  the  treatment,  it  should  be  performed  as  seldom 
as  is  consistent  with  comfort  and  cleanliness.  A  judicious 
use  of  draw-sheets  will  produce  like  results  with  much 
less  disturbance  of  the  patient. 

Nurses  have  invariably  to  be  checked  in  an  extravagant 
use  of  bed  linen.  That  it  is  extravagance  is  difficult  to 
bring  home  to  them  in  a  hospital  ward  where  the  supply 
of  linen  is  bountiful,  and  the  disadvantages  of  too  frequent 
washing  are  not  evident  to  the  pupil.  In  a  properly 
organized  ward  there  are  set  days  and  intervals  for  the 
changing  of  spreads,  curtains,  and  sheets,  and  while 
soiled  and  stained  sheets  must  obviously  always  be  re- 
moved, the  pupils  should  be  taught  that  a  sheet  may  be 
kept  clean  and  fresh  for  double  the  length  of  time  by  such 
simple  means  as  folding  it  smoothly  over  a  chair  during  the 
bath  and  bed-making;  turning  it;  preventing  visitors  from 
sitting  on  the  bed;  protecting  it  with  the  dinner  napkin 
when  food  is  given,  or  with  a  draw-sheet  during  various 


68  PRACTICAL   METHODS 

treatments.  This  may  sound  a  trivial  lesson,  but  if 
really  learnt,  its  usefulness  is  far  reaching.  As  one  of  the 
results  we  might  cease  to  hear  of  private  nurses  taxing 
beyond  bearing  the  resources  of  a  small  establishment 
by  demanding  fresh  sheets,  etc.,  at  least  daily. 

To  Turn  a'Top  Sheet  Without  Exposing  a  Patient.— This 
is  most  easily  done  by  two  nurses.  Standing  one  on  either 
side  of  the  bed,  with  the  blanket  and  spread  removed,  the 
upper  hem  of  the  sheet  is  taken  by  the  hands  furthest 


Fig.  2.— Turning  top  sheet  without  exposing  the  patient. 

from  the  head  of  the  bed.  The  other  hands  are  held 
extended  under  the  reversed  upper  border  of  the  sheet  and 
the  sheet  is  drawn  by  the  upper  hem  over  the  extended 
hands  toward  the  bottom  of  the  bed,  much  as  if  the  upper- 
most hands  formed  a  roller  (Fig.  2). 

Where  a  patient  has  to  remain  any  length  of  time  in 
bed,  it  is  often  an  immense  comfort  to  turn  his  mattress, 
or  to  put  him  on  a  fresh  mattress.  Instruction  in  the 
method  of  so  doing  follows  naturally  the  lessons  in  bed- 
making. 


BEDS    AND    BED-MAKING 


09 


To  Turn  a  Mattress  Under  the  Patient. — First:  Proceed 
as  in  bed-making  until  the  pillows  are  removed  and  the 
patient  covered  with  the  single  blanket. 

Second:  Move  the  patient  to  one  side  of  the  mattress, 
loosen  the  clothes,  and  roll  them  from  either  side  closely 
up  to  him. 

Third:  Take  hold  of  the  mattress  from  the  side  furthest 
from  the  patient,  and  draw  it  across  the  bed  until  half  the 
wire  mattress  is  exposed. 


Fig.  3. — Turning  a  mattress  without  removing  the  patient  from  the 

bed. 

Fourth:  Cover  the  exposed  wire  mattress  with  pillows 
(three  are  enough)  and  move  the  patient,  with  the  bed- 
clothes under  him,  on  to  the  pillows. 

Fifth:  Turn  the  mattress  from  top  to  bottom  (if  advis- 
able, make  it  up  with  clean  sheet  and  draw-sheet),  move 
the  patient  on  to  it,  remove  the  pillows,  and  draw  the 
mattress  back  into  position  (Fig.  3). 

To  Give  a  Fresh  Mattress. — In  a  ward  it  is  usually  as 
simple  a  matter  to  give  a  fresh  mattress  as  to  turn  one 
already  in  use.  Two  methods  may  be  employed: 


70  PRACTICAL   METHODS 

First  Method:  Proceed  as  though  turning  the  mattress, 
but,  instead  of  using  the  pillows,  when  the  mattress  is  drawn 
across  the  bed,  place  a  fresh  mattress  already  made  up 
with  sheet,  etc.,  beside  it,  and  move  the  patient  upon  it. 
Remove  the  old  mattress  and  draw  the  fresh  one  into 
place. 

Second  Method:  Roll  a  second  bed  on  which  is  a  mattress 
without  covers  close  to  that  of  the  patient.  Divest  the 
bed  of  the  upper  clothes  and  pillows,  cover  the  patient 
with  a  single  blanket,  and  loosen  the  under  bed-clothes. 
Two  nurses  standing  at  the  further  side  of  the  empty  bed 
take  hold  of  the  under  sheet  by  the  sides,  and,  slightly 
raising  it,  pull  it  toward  them  with  the  patient  on  it,  helped, 
at  the  same  time  by  a  third  nurse,  who  remains  at  the 
further  side  of  the  patient's  bed.  Where  the  bedstead  is 
of  cot  formation  with  low  railings  at  top  and  bottom, 
two  nurses  stand  at  the  patient's  head  and  feet  and  lift 
him  in  the  sheet  as  though  on  a  stretcher.  Where  a 
patient  can  be  lifted  bodily  from  one  bed  to  another  (or 
on  to  a  couch  or  stretcher),  the  second  bed  is  wheeled 
up  in  such  a  manner  that  the  bottom  of  one  is  opposite 
the  top  of  the  other.  Three  nurses  standing  betwreen  the 
two  beds  lift  the  patient,  one  at  the  shoulders,  one  sup- 
porting the  pelvis,  and  one  at  the  feet;  with  the  beds  so 
arranged,  by  the  nurses  simply  turning  round  in  a  half 
wheel,  the  patient  is  in  the  right  position  to  be  laid  on  the 
fresh  bed.  Sufficient  space  must  be  left  between  the  beds 
to  allow  the  nurses  to  turn  with  the  patient  in  their  arms. 

The  Bed-bath. — After  bed-making  has  been  mastered, 
instruction  in  giving  the  ordinary  cleansing  bed-bath 
follows : 

The  requirements  for  its  performance  are, — a  covering 
for  the  patient,  a  covering  to  protect  the  bed-clothes, 
hot  water  in  a  deep  basin,  a  further  supply  in  a  pitcher, 
a  slop  jar,  a  face  towel,  and  a  second  towel,  thicker  and 
heavier,  two  wash-cloths,  a  bottle  of  alcohol,  and  a  box 
of  talcum  or  starch  powder.  The  water  in  the  basin 
should  be  105°  F.,  that  in  the  pitcher,  110°  F. 

The  bath  may  be  greatly  elaborated  with  scented  soaps 
and  powders,  and  a  variety  of  towels  and  sponges,  or 


BEDS    AND    BED-MAKING 


71 


greatly  simplified,  as  where  a  bowl,  a  small  piece  of 
soap,  and  a  fragment  of  towel  are  all  the  implements 
procurable. 

The  coverings  usually  employed  are  old  blankets,  one 
placed  under  the  patient  and  one  kept  over  him  during 
the  bath.  Where  not  obtainable,  a  half-soiled  sheet, 
folded  in  four  thicknesses,  or  a  large  bath  towel,  may  be 
used  under  the  patient  and  one  of  his  bed  blankets  used 
to  cover  him,  care  being  taken  by  the  use  of  towels  to 
prevent  the  latter  becoming  damp. 


Fig.  4. — Washing  a  patient  without  exposure. 

Where  obtainable,  a  hot-water  bag  ready  filled  should 
be  at  hand,  and  in  most  instances  may  with  advantage  be 
kept  at  the  patient's  feet  during  the  whole  process.  Care 
must  be  taken  that  the  room  is  warm  and  draughts 
excluded. 

The  upper  bed-clothes  removed  and  the  blankets  in 
place,  the  night-shirt  is  removed  and  the  bathing  proceeds 
as  follows,  the  nurse  standing  at  the  right-hand  side  of 
the  bed  (Fig.  4). 


72  PRACTICAL   METHODS 

First:  Sponge  and  dry  the  face:  wash  with  a  good  lather 
of  suds  the  neck  and  ears,  rinse  well,  and  dry,  taking  par- 
ticular care  with  the  ears. 

Second:  Bring  each  arm  in  turn  out  over  the  upper 
blanket,  place  the  basin  on  the  bed,  and  put  the  hand 
in  the  water,  soaping  and  rubbing  it  between  your  own 
hands.  Keep  each  hand  in  the  water  while  the  arm  is 
washed.  Rinse,  dry  thoroughly,  and  repeat  the  process 
with  the  other  arm. 

Third  (the  second  wash-cloth  is  now  used):  Wash  the 
chest  and  abdomen.  This  may  or  may  not  be  done  under 
cover,  at  discretion.  Where  a  patient  is  washed  under 
cover,  the  blanket  is  with  one  hand  held  slightly  away  from 
the  body,  while  the  other  hand  performs  the  washing  and 
drying.  The  entire  patient  may  be  washed  in  this  way, 
and  should  be  so  done  where  discretion  suggests,  or  where 
the  patient  is  peculiarly  susceptible  to  chill,  as  in  condi- 
tions of  great  weakness. 

The  axilla  and  umbilicus  must  receive  special  care.  If 
the  umbilicus  has  been  neglected  and  allowed  to  become 
blocked  with  secretion  and  dust  difficult  to  remove,  a 
small  soap  poultice  may  be  applied  twice  a  day  until 
clean.  (See  Preparation  for  Operation,  p.  567.) 

Fourth:  The  chest  and  abdomen  dried  and  covered,  the 
genitals  are  carefully  washed  under  cover.  In  many 
cases  patients  can  do  this  for  themselves  with  some  little 
assistance  from  the  nurse.  With  helpless  or  unconscious 
patients  it  must  not  be  neglected  from  a  false  notion  of 
delicacy,  the  skin  in  these  parts  becoming  easily  inflamed 
and  sore  from  the  natural  secretions,  unless  kept  scrupu- 
lously clean.  The  folds  of  the  thighs  should  receive 
special  attention. 

Where  the  parts  have  become  irritated,  or  from  any 
cause  are  difficult  to  cleanse  (such  as  during  menstruation), 
such  washing  may  be  left  to  the  end  of  the  bath,  and  the 
patient  placed  on  a  douche  pan,  filled  with  hot  water,  and 
given  a  thorough  local  tubbing. 

Fifth:  At  this  point  the  water  usually  requires  changing 
and  the  basin  is  replenished  from  the  pitcher. 

The  lower  limbs  are  now  exposed  in  turn,  washed  and 


BEDS    AND    BED-MAKING  73 

dried  in  turn  in  the  same  way  as  the  arms,  with  the  basin 
on  the  bed  and  the  foot  kept  in  the  hot  water.  This  method 
of  bathing  the  limbs  demands  a  little  more  dexterity,  so 
as  not  to  upset  the  basin,  and  cannot  be  used  with  a  rest- 
less patient,  but  it  is  usually  found  immensely  comfortable 
for  the  patient,  and  is  a  good  means  of  restoring  the 
bodily  warmth,  which  is  always  slightly  lost  in  washing. 

Sixth:  The  patient  is  rolled  over  on  his  face  and  the 
back  and  hips  washed. 

If  it  is  an  object,  as  in  many  cases,  to  spare  the  patient's 
strength,  the  under  sheet  may  now  be  changed,  and  the 
patient  turned  on  to  the  freshly  made  half  of  the  bed, 
the  under  washing  blanket  is  removed  with  the  soiled 
sheet,  the  entire  bath  and  bed-making  being  thus  ac- 
complished with  only  one  turning  of  the  patient,  a  con- 
sideration when  the  store  of  strength  is  small. 

Seventh:  Before  the  shirt  is  replaced  the  back,  hips, 
and  other  points  of  pressure  are  usually  well  rubbed  with 
alcohol  and  powdered. 

Eighth:  The  shirt  is  replaced  and  the  bed  made. 

The  bed-bath  is  usually  the  most  acceptable  if  the  wash- 
ing is  done  briskly  with  plentiful  soap,  thorough  rinsing, 
and  a  fairly  vigorous  friction  with  a  dry  towel,  none  of 
which  is  incompatible  with  gentleness;  the  unpleasantness 
and  inadequacy  of  a  dabbing  wash  with  a  wash-cloth 
wrung  nearly  dry,  followed  by  a  gentle  wiping,  has  to  be 
experienced  to  be  realized. 

Changing  the  Shirt. — In  removing  a  patient's  shirt, 
loosen  it  round  the  neck,  bring  the  back  half  over  the 
shoulders,  and  draw  off  one  sleeve,  when  the  shirt  will 
slip  easily  over  the  head  and  be  withdrawn  by  the  second 
sleeve.  Should  one  arm  or  side  be  injured,  begin  always 
with  the  sound  arm. 

In  putting  on  a  shirt,  reverse  the  proceedings,  thus,  first 
one  sleeve,  an  injured  arm  first,  then  over  the  head,  then 
the  second  sleeve,  and  finally  pull  it  down  comfortably 
under  the  patient.  In  putting  on  the  sleeve  make  it  as 
short  as  possible  by  gathering  the  wristband  up  toward 
the  arm-hole,  antl  so  slipping  the  entire  sleeve  over  the 
wrist  with  one  movement. 


74  PRACTICAL  METHODS 

Simple  as  this  lesson  sounds,  usually  it  has  to  be  prac- 
tised again  and  again  before  it  is  accomplished  with  deft- 
ness, and  with  no  fatigue  for  the  patient. 

For  hospital  use  a  very  practical  shirt  is  often  sup- 
plied, buttoning  behind,  with  the  front  part  the  usual 
length  and  the  back  reaching  only  to  the  waist.  It  is 
comfortable  for  such  patients  as  are  forced  to  lie  down,  and 
can  be  changed  quickly.  Its  disadvantages  are  that  it 
is  frequently  used  for  patients  that  can  sit  up,  where  it 
is  obviously  unsuitable,  and  that  its  use  leads  pupil  nurses 
to  believe  they  cannot  nurse  a  bedridden  patient  with  the 
ordinary  night-shirts.  As  a  consequence,  many  nurses 
invariably  tear  their  patient's  shirts  the  whole  length 
behind,  regardless  of  the  fact  that  they  are  needlessly 
destroying  property  not  their  own,  and  incurring  just 
censure  for  extravagance  and  wastefulness.  In  the  few 
instances  in  which  such  a  shirt  is  the  best  for  a  patient's 
welfare,  the  oldest  shirts  should  be  asked  for,  and  should 
be  neatly  altered  to  suit  the  requirements,  not,  as  is  the 
too  frequent  method,  simply  torn  and  fastened  with  a 
safety-pin. 

Care  of  the  Mouth. — Where  a  patient  is  capable  of  doing 
so,  he  should  brush  his  teeth  in  the  ordinary  way  at  least 
morning  and  evening.  Where  he  cannot  do  so,  his  mouth 
should  receive  the  most  careful  attention  from  the  nurse. 

In  almost  all  forms  of  illness,  and  frequently  in  patients 
on  a  purely  liquid  diet,  the  tongue  will  be  found  covered 
with  a  coating  or  fur  which  is  largely  composed  of  food- 
particles,  epithelial  scales  from  the  mucous  membrane 
of  the  mouth,  and  bacteria,  mixed  with  the  secretions  of 
the  mouth.  If  the  mouth  is  not  kept  sufficiently  clean, 
the  fur  accumulates  and  spreads  to  the  teeth,  gums,  and 
lips  in  the  form  of  a  thick,  tenacious,  brown  deposit,  diffi- 
cult to  remove,  and  known  as  sordes  (pronounce  sordees). 
In  health  the  muscular  action  of  the  tongue,  cheeks,  and 
lips  in  the  process  of  chewing  food  keeps  the  mouth  free 
from  such  deposits. 

In  severe  illness  the  tongue  may  become  intensely  dry 
and  dark  in  color,  while  deep  cracks  or  fissures  appear, 
difficult  to  cleanse  or  to  cure.  Not  infrequently  a  neglected 


BEDS   AND    BED-MAKING 


75 


mouth  becomes  ulcerated,  the  ulcers  extending  to  the 
gums  and  cheeks  and  causing  acute  suffering. 

It  should  be  borne  in  mind  that  a  neglected  mouth  is 
a  menace  to  the  entire  system.  The  mouth  is  freely 
supplied  with  lymphatics  ready  to  carry  the  products  of 
infection  over  all  the  body.  It  presents  an  ideal  condi- 
tion for  the  development  of  the  disease-producing  germs, 
which  require  for  their  development  moisture,  warmth, 
absence  of  light,  and  suitable  food,  which  they  find  in  the 
body  in  its  organic  tissue;  and  we  know  that  the  germs 
of  many  diseases  are  found  in  the  mouth,  even  in  health. 
Many  cases  of  reinfection  in  typhoid  fever  are  considered 
attributable  to  a  neglected  mouth,  while  the  frequency  with 
which  the  adjacent  glands  or  the  middle  ear  become  in- 
fected in  illnesses  associated  with  abnormal  conditions  of 
the  throat  or  mouth  is 
a  familiar  example  of 
the  necessity  for  vigi- 
lant cleanliness. 

A  small  tray  (a  white 
enamel  pie-dish  will 
serve)  (Fig.  5)  may  be 
fitted  up  with  the  re- 
quisites for  cleansing 
the  mouth.  These  con- 
sist of  a  bottle  of  mouth- 
wash,  a  small  tumbler 
or  gallipot  into  which 
the  amount  required  at 
one  time — and  no  more 

—is  poured,  and  a  second  gallipot  to  hold  a  supply  of 
applicators.  The  most  practical  are  made  of  short 
sticks  of  match-wood,  to  one  end  of  which  are  attached 
pledgets  of  absorbent  cotton.  The  pledget  is  formed 
of  a  strand  of  absorbent  cotton  wound  on  the  end  of 
the  applicator.  It  should  not  be  thick.  As  the  fingers 
must  be  used  in  mounting  the  cotton  on  the  applicators, 
the  hands  must  be  scrupulously  clean.  The  habit  of 
wrapping  a  piece  of  gauze  round  the  finger  and  so  cleans- 
ing the  patient's  mouth  should  not  be  permitted.  It  is 


Fig.  5. — Tray  for  care  of  mouth. 


76  PRACTICAL   METHODS 

clumsy,  unpleasant  for  both  patient  and  nurse,  and,  except 
with  infants,  inadequate.  For  infants  it  is  practical,  the 
natural  sucking  movements  helping  in  the  cleansing. 

Pass  the  applicator,  moistened  in  the  mouth-wash, 
carefully  and  repeatedly  over  the  tongue  and  every  corner 
of  the  mouth,  paying  special  attention  to  the  roof  of  the 
mouth  and  the  crevices  between  the  gums  and  cheek,  and 
changing  the  applicator  frequently.  Repeat  the  process 
until  all  the  deposit  that  is  movable  is  removed.  Do  not 
dip  a  used  applicator  into  the  mouth-wash,  but  use  a 
fresh  one  each  time.  If  the  patient  is  strong  enough, 
let  him  rinse  his  mouth  after  into  a  small  receiver. 

Lay  each  applicator  after  use  on  the  tray;  later  it  may 
be  washed,  disinfected,  remounted,  and  used  again  for 
the  same  patient,  the  soiled  pledgets  being  removed  with 
forceps.  Where  the  mouth  contains  an  open  wound,  as 
after  a  mouth  operation,  or  in  a  case  of  compound  fracture 
of  the  jaw,  the  applicators  must  be  sterilized  like  any 
other  surgical  dressing,  and  may  be  put  up  conveniently 
in  packets  of  half  a  dozen  ready  for  use. 

A  mouth-wash  should  be  antiseptic  and  cleansing  and 
have  no  unpleasant  taste  or  property  injurious  to  the 
mucous  membrane.  Strong  antiseptics  or  powerful  drugs 
are  not  suitable,  owing  to  the  danger  of  absorption,  and, 
if  necessary  to  be  used,  should  be  followed  by  thorough 
rinsing  with  sterile  water.  They  should  never  be  employed 
for  children  who  are  apt  to  swallow  the  mouth-wash. 
The  most  commonly  used  are  listerine  and  water;  boric 
acid  and  water,  alone  or  mixed  with  a  little  glycerin  and 
lemon-juice;  myrrh  or  thymol  well  diluted,  chlorate  of 
potash  (5  grains  to  the  ounce  of  water),  and  permanganate 
of  potash,  a  few  crystals  to  a  tumbler  of  water.  The 
latter  is  the  least  expensive  and  is  frequently  used  in 
district  work.  Where  the  mouth  is  in  danger  of  becoming 
infected,  as  in  the  case  where  cracks  and  fissures  have 
formed,  equal  parts  of  lime-water  and  peroxid  (dioxid)  of 
hydrogen  is  the  most  efficacious  wash,  but  the  mouth  should 
be  carefully  rinsed  after  its  use.  Where  the  mouth  is  very 
dry  or  ulcerated,  a  light  application  of  albolene  or  dilute 
boroglycerid  after  the  cleansing  is  beneficial.  Glycerin 


BEDS  AND  BED-MAKING  77 

alone,  although  healing,  is  too  astringent.  In  cases  of 
severe  ulceration  special  applications  are  usually  ordered, 
such  as  solution  of  chlorate  of  potash,  nitrate  of  silver, 
sulphate  of  copper,  and  so  forth.  The  cleansing  of  the 
mouth  should  precede  the  application. 

Patients  on  a  liquid  diet  should  have  their  mouths 
cleansed  before  each  feeding.  To  cleanse  after  is  apt 
to  induce  retching  and  possibly  vomiting.  Where  the 
tongue  is  brown  and  cracked,  marked  improvement  is 
shown  if  the  patient  is  induced  to  drink  water  freely. 
Fever  patients  who  from  the  beginning  have  had  plenty 
of  water  much  less  frequently  develop  the  brown,  dry, 
and  fissured  tongue.  The  point  should  be  impressed  on 
nurses,  who  are  somewhat  apt  to  give  water  only  when 
the  patient  complains  of  thirst. 

Care  of  the  Back. — Prevention  and  Treatment  of  Bed- 
sores.— After  the  daily  bath,  as  has  already  been  said, 
the  back,  hips,  and  other  points  of  pressure  should  be 
rubbed  with  alcohol  and  dusted  with  powder — usually 
starch  or  borated  talcum;  rice,  zinc,  or  perfumed  powders, 
equally  efficacious,  are  more  expensive.  The  reason 
for  the  rubbing  is  twofold:  by  thorough  drying  to  prevent 
the  skin  from  becoming  chafed,  and  by  friction  to  re- 
store the  circulation  to  parts  where,  from  continued  press- 
ure, it  is  in  danger  of  becoming  lessened.  The  points 
of  pressure  in  order  of  their  importance  are:  the  coccyx 
(the  prominence  at  the  end  of  the  spine),  the  hips,  elbows, 
heels,  shoulders,  the  inner  surfaces  of  the  ankles  and  knees, 
and  the  back  of  the  head,  the  latter  chiefly  in  young 
children.  All,  it  will  be  observed,  are  bony  prominences 
protected  only  by  a  thin  covering  of  skin. 

With  no  other  cause  the  weight  of  the  body  for  a  length- 
ened period  on  one  spot  is  sufficient  to  produce  redness 
of  that  part,  with  a  sensation  of  heat,  aching,  and  dis- 
comfort. If  these  symptoms  are  neglected,  we  have 
the  first  stage  of  a  bed-sore.  From  the  beginning  of  her 
training  it  cannot  be  too  emphatically  laid  before  the 
pupil  that  for  a  patient  in  her  charge  to  acquire  a  bed-sore 
points  to  culpable  neglect  on  her  part,  so  rare  are  the  cases 
in  which  it  may  be  considered  unpreventable. 


78  PRACTICAL   METHODS 

Besides  pressure  from  the  weight  of  the  body,  the 
common  causes  of  a  bed-sore  are  moisture,  wrinkles  in  the 
bed-clothes,  crumbs  in  the  bed,  want  of  cleanliness,  and 
bruising  from  the  careless  giving  of  a  bed-pan. 

The  most  important  part  of  the  treatment  of  a  bed-sore 
is  to  prevent  its  forming.  To  accomplish  this,  prevent 
pressure,  or  relieve  it  by  change  of  position  at  the  first 
sign  of  discomfort  or  appearance  of  redness,  and  practise 
a  methodic  and  systematic  routine  of  cleanliness.  Wash 
the  parts  daily  with  soap  and  water,  drying  thoroughly 
and  following  the  operation  by  a  thorough  alcohol  rub 
and  powdering.  Repeat  the  alcohol  rub  in  the  middle 
of  the  day  and  in  the  evening,  at  the  same  time  brushing 
the  bed  free  of  crumbs  and  drawing  and  smoothing  the 
draw-sheet.  For  emaciated  patients,  or  patients  in  whom, 
for  a  variety  of  causes,  the  circulation  is  feeble,  the  above 
will  not  be  sufficient.  Many  cases  occur  where  the  posi- 
tion should  be  changed  every  hour,  and  the  parts  that 
have  borne  the  weight  carefully  rubbed  and  powdered 
with  each  turning.  In  ward  work  the  hours  at  which  a 
patient's  "  back  "  is  to  be  rubbed  and  attended  to  should 
be  assigned  as  carefully  as  the  hours  at  which  his  medicines 
are  to  be  administered,  and  as  punctually  adhered  to. 

In  some  patients  the  skin  has  a  tendency  to  chafing 
and  the  formation  of  cracks.  In  these  cases  the  skin  may 
be  preserved  whole  by  an  application  of  castor  oil  and 
collodion,  equal  parts,  painted  over  the  surface  and  re- 
applied  when  necessary.  The  dressing  is  not,  however, 
any  protection  from  pressure-sores. 

Bed-sores  may  be  broadly  classed  under  two  headings: 
those  caused  by  an  abrasion  of  the  outer  skin  and  those 
caused  by  restriction  of  the  circulation.  The  former 
appear  first  as  a  redness  of  the  parts  if  over  a  prominence, 
or  as  a  crack  in  a  fold  of  flesh,  such  as  in  the  groin  or  the 
fold  of  the  buttocks.  A  few  hours'  neglect  is  sufficient 
for  the  skin  to  break,  and  we  presently  have  a  shallow 
sore  with  a  moist  surface,  surrounded  by  sound  flesh. 
This  is  the  mildest  form  of  the  bed-sore,  and  if  checked 
at  this  point,  may  heal  quickly.  Pressure  must  be  at 
once  removed  either  by  change  of  position  or  a  judicious 


UKDS    AND    BKD-MAKINC  79 

arrangement  of  pillows.  The  wound  must  be  kept 
surgically  clean  and  dry,  the  surrounding  tissues  sound. 
If  the  crack  is  in  a  fold  of  flesh,  the  surfaces  must  be 
kept  apart.  The  most  satisfactory  application  is  a  sterile, 
mildly  antiseptic  dusting-powder  constantly  applied, 
such  as  starch  or  talcum  and  boric,  starch  and  zinc,  or 
stearate  of  zinc;  the  latter  is,  however,  much  more  ex- 
pensive than  the  others.  Ointments  are  at  the  present 
day  out  of  favor,  but  in  cases  difficult  to  keep  dry  a  piece 
of  lint  spread  with  zinc  ointment  the  size  of  the  sore, 
covered  with  a  piece  of  sterile  gauze,  and  held  in  place 
by  strips  of  adhesive  strapping,  is  frequently  a  successful 
dressing.  If  the  sore  is  progressing  favorably,  the  sur- 
face will  become  clean  and  dry,  and  new  granulations, 
in  the  form  of  bright  red  specks,  may  be  observed.  We 
have,  however,  a  wounded  surface,  and,  as  in  all  wounds, 
there  is  consequently  danger  of  infection.  The  signs  of 
such  infection  are  discharge  and  local  inflammation;  the 
granulations  are  pale  and  unhealthy;  the  sore,  instead  of 
healing,  grows  deep.  The  bed-sore  is  treated  like  any 
other  surgical  wound  that  is  not  healing  by  first  intention. 
It  is  cleansed  with  an  antiseptic  solution,  and,  usually 
after  powdering,  lightly  packed  with  gauze  and  covered 
with  a  gauze  pad.  If  stimulation  is  required,  the  surface 
is  sometimes  touched  with  nitrate  of  silver  or  blue  stone, 
or  an  astringent  lotion,  such  as  zinc  wash,  may  be  used. 
The  dressing  is  renewed  whenever  it  has  become  damp  or 
soiled.  Such  bed-sores,  beginning  mildly,  may  become 
large,  deep  ulcers,  causing  great  suffering  and  taking  weeks 
to  heal. 

The  second  variety  of  bed-sore  has,  at  the  beginning, 
the  appearance  of  a  bruised  spot,  dark  purple  in  color, 
and  occurring  most  frequently  over  the  coccyx.  It  is 
the  result  of  pressure,  and  sometimes  caused  by  such  an 
apparently  trifling  matter  as  leaving  a  patient  for  a  length 
of  time  with  his  back  pressing  on  a  bed-pan.  Only  rarely 
is  it  possible  to  avert  a  bed-sore  once  this  bruised  spot  is 
noticed.  This  variety  of  sore  is  also  caused  by  badly 
adjusted  splints  or  mechanical  appliances.  Pressure  must 
be  promptly  relieved,  and  the  surrounding  tissues  gently 


SO  PRACTICAL   METHODS 

but  thoroughly  rubbed  to  restore  the  circulation.  The 
remedies  advocated  at  this  stage  are  bathing  with  very 
hot  water  for  ten  minutes  at  a  time,  repeated  hourly, 
painting  the  surface  with  the  three  tinctures  (tincture 
of  aconite,  1|  drams,  tincture  of  opium,  1^  drams,  tincture 
of  iodin,  5  drams),  or  strapping  applied  directly  over  the 
discolored  spot.  At  the  very  first  symptom  of  discolora- 
tion each  of  these  remedies  has  been  known  to  have  good 
results,  especially  if  pressure  can  be  entirely  removed. 
Frequently,  however,  it  is  apparent  that  a  slough  has 
already  formed,  which  must  come  away  before  healing 
can  begin.  A  slough  is  a  piece  of  dead  flesh  in  living  flesh, 
and  is  the  same  thing  in  soft  tissues  that  a  sequestrum  or 
necrosed  bone  is  in  hard  tissue  (p.  657).  It  cannot  be 
revitalized  or  absorbed.  When  a  slough  has  remained 
attached  until  it  has  become  decomposed,  it  is  called  a 
gangrene,  and  has  a  characteristic,  very  offensive  odor. 
The  separation  of  the  slough  may  be  hastened  by  the 
application  of  hot  compresses  or  a  small  poultice  cut 
exactly  the  size  of  the  slough,  and  covered,  when  applied, 
with  some  moisture-proof  protective,  such  as  light  mack- 
intosh sheeting  or  gutta-percha  tissue.  When  the  slough 
begins  to  separate,  it  must  never  be  pulled  away,  or  hem- 
orrhage, difficult  to  control,  may  result.  When  the 
slough  is  shed,  a  correspondingly  deep  sore  is  revealed, 
with  a  discharging,  irregular  surface.  Probing  will  fre- 
quently discover  small  channels  burrowing  more  deeply 
into  the  tissues.  Such  sores  are  very  liable  to  secondary 
infection  and  to  increase  in  size  with  rapidity,  sometimes 
becoming  so  large  as  to  threaten  life  from  the  drain  they 
cause  to  the  system,  and  from  the  toxins  absorbed. 

The  treatment  aims  at  preventing  infection  and  induc- 
ing healing:  usually  the  bed-sore  is  cleaned  with  peroxid 
of  hydrogen  daily,  and  packed  with  sterile  gauze,  some- 
times soaked  with  such  preparations  as  bovinin,  balsam 
of  Peru,  or  a  weak  solution  of  zinc  (2  grains  to  the  ounce), 
known  as  red  wash;  or  the  surface  is  dusted  with  sterile 
dusting-powder  and  packed  with  dry  gauze.  The  dress- 
ing must  be  performed  under  strict  surgical  asepsis.  If  the 
surface  is  extensive,  poisonous  applications  must  be  used 


BEDS   AND    BED-MAKING  81 

with  caution.  Patients  have  exhibited  symptoms  of 
acetanilid  poison  from  the  use  of  acetanilid  in  the  dusting- 
powder  of  a  bed-sore  insignificant  in  size.  Where  the 
surface  of  the  wound  is  pale  and  unhealthy  in  appearance, 
it  is  usual,  from  time  to  time,  to  use  a  stringent  applica- 
tion in  the  dressing.  Usually  the  surface  is  painted  with  a 
solution  of  nitrate  of  silver  (2  grains  to  the  ounce),  or 
the  silver  stick  (lunar  caustic)  is  applied  directly.  If, 
on  healing,  the  granulations  have  a  tendency  to  become 
redundant,  the  same  treatment  is  also  followed  to  reduce 
them.  When  the  bed-sore  is  healing  properly,  the  dis- 
charge decreases,  the  surface  is  a  healthy  red  color,  and 
the  wound  is  perceptibly  smaller  day  by  day.  Not  only 
will  the  cavity  close  up  from  the  bottom,  but  healing  will 
be  carried  on  from  the  margins  of  the  wound,  as  in  the  case 
of  an  ulcer. 

Sometimes  the  first  appearance  of  a  bed-sore  is  a  red- 
dened area,  which  is  also  puffy  or  swollen,  with  one  or 
more  clear  blisters  formed  on  the  surface.  The  blister 
results  from  a  pinching  of  the  swollen  tissue  which  has 
caused  a  small  local  exudation  of  lymph.  If  pressure 
is  removed,  the  part  rubbed  thoroughly  and  powdered, 
care  being  taken  not  to  break  the  blister,  the  symptoms 
will  frequently  subside  and  the  contents  of  the  blister 
be  gradually  absorbed.  If  the  blister  breaks,  it  is  a  sore 
similar  to  those  first  described.  The  cuticle  of  the  blister 
should  not  be  cut  away  unless  the  sore  becomes  infected, 
when  a  free  surface  is  a  more  favorable  condition  than 
a  covered  surface. 

It  should  be  a  strict  rule  in  all  wards  that  the  earliest 
symptoms  of  a  bed-sore  should  be  reported  to  the  head 
nurse,  and  by  her  to  the  doctor.  This  is  sometimes 
neglected  from  a  dislike  of  incurring  blame. 

To  Relieve  Pressure. — Where  the  patient  may  be  turned, 
to  turn  him  is  the  best  means  of  relieving  pressure.  Where 
the  position  is  fixed,  pressure  may  be  relieved  by  the  ad- 
justment of  pillows  of  various  sizes  or  the  use  of  a  ring 
cushion.  Ring  cushions  are  made  of  rubber  in  ring  shape 
and  inflated  with  air.  They  should  be  inflated  just  suffi- 
ciently to  relieve  the  pressure  and  no  more,  otherwise  they 

6 


82  PRACTICAL    METHODS 

are  hard  and  uncomfortable.  They  may  be  covered  with 
a  clean  gauze  bandage  wound  smoothly  round  and  round 
the  ring.  Besides  the  ring  pillow  of  rubber,  small  rings 
of  many  sizes  may  be  cut  out  of  muslin  and  stuffed  with 
tow  pulled  smooth  or  with  non-absorbent  cotton.  They 
are  invaluable  in  removing  pressure  from  such  points  as 
the  heels,  knees,  elbows,  or  ankle  bones.  Small  pads  and 
pillows  may  be  used  in  the  same  way  and  can  be  made 
any  suitable  size,  from  a  few  inches  square  up.  If  neces- 
sary, they  may  be  kept  in  position  by  a  light  bandage. 

Where,  as  in  cases  greatly  emaciated,  there  is  a  tendency 
to  redness  in  many  parts  of  the  body,  the  patient  may  be 
nursed  on  an  air-  or  water-bed.  Such  a  bed  consists 
of  a  rubber  mattress,  either  inflated  with  air  or  filled  with 
water,  and  placed  above  the  ordinary  mattress,  and  gen- 
erally proves  an  immense  comfort  to  the  patient.  To 
prevent  sagging,  two  or  three  boards  should  be  placed 
across  the  bed  under  the  wire  mattress,  or  the  hair  mat- 
tress may  be  replaced  by  a  straw  palliasse.  The  rubber 
mattress  should  be  protected  by  a  rubber  sheet  and  a 
blanket  tucked  well  in  before  the  usual  bed-clothes  are 
arranged  in  place.  The  smallest  pin-prick  will  spoil  the 
entire  usefulness  of  the  mattress,  each  of  which  cost  from 
$25  to  $40. 

If  water  is  used,  it  should  be  at  a  temperature  comfort- 
ably warm,  and  watch  must  be  kept  from  time  to  time  to 
see  that  the  warmth  is  maintained.  If  it  becomes  chilled, 
some  of  the  water  is  removed  and  hot  water  added, 
which  can  be  done  without  taking  the  patient  off  the 
mattress. 

In  order  to  place  a  patient  on  a  water-bed  the  best 
method  is  to  prepare  it  on  a  second  bed  and  then  move 
the  patient.  Where  this  is  not  possible,  the  empty  rubber 
bed  may  be  placed  under  the  patient  in  the  same  way  that 
a  sheet  is  rolled  beneath  him,  and  filled,  when  in  place,  with 
remarkably  little  disturbance  of  the  patient. 

To  Give  a  Bed-pan. — The  careless  giving  of  a  bed-pan 
may  so  bruise  the  coccyx  as  to  lead  to  the  formation  of  a 
bed-sore.  This  small  office  for  the  sick  may  be  a  source 
of  acute  discomfort  if  done  roughly  or  without  due  regard 


BEDS   AND    BED-MAKING  83 

for  the  natural  delicacy  of  a  patient.  No  bed-pan  should 
be  given  without  a  screen  round  the  bed  or  the  bed- 
curtains  drawn,  and  this  rule  should  be  equally  enforced 
at  night  and  in  children's  wards. 

To  give  the  bed-pan,  place  the  left  hand  under  the  pelvis 
and  raise  the  patient  sufficiently,  directing  him  at  the  same 
time  slightly  to  draw  the  knees  up  and  press  the  heels 
against  the  bed;  with  the  right  hand  slide  the  pan  under 
the  patient,  and  gently  lower  him  in  the  proper  position. 
Have  a  folded  towel  or  suitable  pad  where  the  patient's 
back  will  rest,  and  avoid  knocking  the  back  with  rough  or 
jerky  movements.  Where  patients  are  unable  to  attend 
to  themselves  after  its  use  it  must  be  done  for  them,  as 
quietly  and  as  much  as  a  matter  of  course  as  any  other 
service  rendered. 

Bed-pans  are  made  in  several  shapes;  that,  however, 
similar  to  those  supplied  by  Meinecke  and  Company, 
No.  48  Park  Place,  New  York,  and  named  the  Perfection, 
is  at  present  in  almost  universal  use  in  hospitals.  It  is 
simple  to  clean  and  comfortable  for  the  patient.  It 
comes  in  either  porcelain  or  gray  or  white  enamel;  the 
enamel,  although  more  expensive  to  begin  with,  is  cheaper 
in  the  end,  as  with  reasonable  care  to  prevent  chipping 
the  enamel  will  last  a  very  long  time  in  good  condition. 
Another  shape  which  fulfils  an  occasional  want  is  the 
slipper  bed-pan,  made  in  the  shape  of  a  wedge.  It  is  of 
use  where,  either  from  extraordinary  weight  or  from  the 
necessity  of  a  specially  fixed  position,  the  patient  cannot 
be  raised  from  the  bed  even  the  few  inches  necessary  to 
place  the  usual  bed-pan  in  position.  Bed-pans  may  also 
be  obtained  made  entirely  of  rubber.  They  are  chiefly 
used  in  cases  of  incontinence  where  it  may  be  necessary  to 
keep  the  bed-pan  permanently  under  the  patient.  (See 
Care  of  Rubber,  p.  483.) 

In  carrying  a  bed-pan  to  and  from  a  patient,  it  should 
invariably  be  covered.  A  piece  of  stout  cotton  or  ticking 
three-quarters  of  a  yard  square  makes  an  adequate  cover- 
ing, and  must  be  kept  strictly  for  its  purpose. 

After  use,  the  bed-pan  must  be  at  once  removed  and 
washed,  first  in  a  stream  of  cold  water,  and  then  thoroughly 


84  PRACTICAL   METHODS 

mopped  and  rinsed  with  hot  water.  If  the  case  is  an 
infectious  one,  it  may  be  necessary  to  mix  the  contents 
thoroughly  with  a  disinfectant  and  allow  it  to  stand  for 
a  given  time.  In  this  case  it  must  be  closely  covered  and 
emptied  as  soon  as  possible.  (See  Infection  and  Im- 
munity.} 

From  the  beginning  nurses  must  be  taught  that  the 
condition  of  the  excreta  is  an  important  indication  of 
many  conditions  of  the  system  (see  Excreta),  and  they 
should  be  trained  to  detect  any  deviation  from  the  normal 
and  to  report  to  the  head  nurse,  and  save  for  her  inspection 
any  stool  or  specimen  in  any  way  unusual. 

Care  of  the  Hair. — In  a  woman's  ward  the  proper  care 
of  the  patient's  hair  is  a  considerable  item  in  the  daily 
work.  The  hair  should  be  thoroughly  brushed  once  a 
day,  and  again,  not  necessarily  so  thoroughly,  at  the 
evening  toilet.  For  a  patient  lying  down  it  is  most 
conveniently  arranged  by  parting  the  hair  from  brow  to 
the  back  of  the  neck  and  braiding  it  on  either  side  of 
the  head.  In  this  way  it  is  kept  free  of  tangles,  is  easily 
groomed,  and  is  out  of  the  way  of  the  patient. 

Where  the  hair  has  become  badly  tangled  through 
carelessness  or  want  of  skill,  it  requires  an  immense  amount 
of  patience  and  considerable  skill  to  disentangle  it  without 
torturing  the  patient.  Vaselin  or  sweet  oil  rubbed  freely 
into  the  hair  will  help  matters.  The  hair  should  then  be 
brushed,  a  small  portion  at  a  time,  beginning  at  the  ends, 
and  not  at  the  roots.  To  avoid  tugging  on  the  roots,  each 
strand  should  be  held  firmly  in  the  left  hand  just  above  the 
portion  being  brushed.  The  portion  free  of  tangles  is 
then  braided,  and  the  next  portion  attacked. 

It  is  customary  to  wash  the  heads  of  ward  patients  on 
admission  to  the  ward.  Where  a  patient  is  unable  to  get 
out  of  bed,  proceed  as  follows  (Fig.  6) : 

First:  Provide,  on  a  convenient  table,  a  deep  basin  with 
hot  water  (temp.,  105°  F.),  a  pitcher  of  water  (110°  F.), 
a  slop-jar,  a  bottle  of  liquid  green  soap,  a  small  pitcher, 
towels,  a  small  rubber  sheet,  and  a  Kelly  pad.  Where  a 
Kelly  pad  is  not  available,  one  can  be  improvised  by  rolling 
a  small  blanket  into  one  end  of  a  rubber  sheet  and  folding 


BEDS   AND   BED-MAKING  85 

into  a  horseshoe  shape,  the  free  end  acting  as  the  apron  of 
the  Kelly  pad. 

Second:  Place  the  Kelly  pad  under  the  patient's  head 
near  the  edge  of  the  bed.  Arrange  so  that  cheek  and  side 
of  the  neck  rest  on  the  inflated  rim  of  the  pad,  with  the 
hair  brushed  away  from  the  face.  The  apron  of  the  Kelly 
pad  is  directed  into  the  slop-pail,  which  is  conveniently 
placed  below  the  bed. 


Fig.  6. — Washing  the  hair  of  a  woman  patient  in  bed. 

Third:  Fold  a  small  rubber  sheet  covered  with  a  towel 
closely  round  the  neck  (a  bath  towel  preferably),  and  pin 
them  securely  in  place;  roll  a  second  small  towel,  pass  it 
from  the  back  of  the  neck  over  the  ears  across  the  brow 
above  the  eyes,  taking  care  to  cover  none  of  the  hair; 
secure  it  firmly  with  a  safety-pin. 

Fourth:  Wash  the  hair,  first  wetting  it,  then  pouring  on 


86  PRACTICAL   METHODS 

sufficient  soap  and  massaging  the  scalp  thoroughly  with 
the  hands  moving  in  opposite  directions.  Repeat  with 
fresh  water  until  clean.  A  little  ammonia  may  be  added 
to  the  first  water  with  advantage. 

Fifth:  Rinse  by  pouring  water  over  the  head  with  the 
small  pitcher,  moving  the  hair  about  so  that  the  roots  are 
reached. 

Sixth:  When  thoroughly  rinsed,  wring  the  hair  gently 
with  both  hands,  remove  the  Kelly  pad,  and  replace  it 
with  the  small  rubber  sheet  from  the  shoulders;  unpin  the 
large  towel  and  turn  in  over  the  entire  head;  remove  the 
rolled  face  towel  and  rub  the  hair  until  dry.  The  drying 
process  may  be  hastened  by  fanning  with  one  hand,  at  the 
same  time  separating  the  strands  of  hair  with  the  other. 
In  washing  the  hair  it  must  be  closely  examined  for  pediculi, 
which  are  very  common  among  ward  patients.  The  eggs 
appear  very  much  like  specks  of  dandruff,  but  adhere 
closely  to  the  hair  and  cannot  be  removed  by  a  fine  comb. 
All  heads  in  a  general  ward  should  be  closely  combed  on 
admission,  and  if  either  pediculi  or  eggs  (nits)  are  found, 
should  be  treated  until  cured  with  a  head  lotion  and  care- 
ful combing. 

To  Treat  a  Head  With  Pediculi. — After  washing,  the 
hair  is  soaked  either  in  a  disinfectant,  such  as  bichlorid 
of  mercury,  1 :  500,  carbolic  acid,  1 : 40,  in  tincture  of 
larkspur,  or  in  coal  oil,  and  is  then  wrapped  in  a  triangular 
bandage  or  towel.  If  coal  oil  is  used,  care  must  be  taken 
that  no  friction  is  used  and  that  no  lamp  or  other  light  is 
allowed  near.  Frequently,  in  the  homes  of  the  poor,  coal 
oil  is  the  only  available  remedy.  The  coal  oil  may  be 
applied  at  bedtime.  The  next  morning  the  hair  is  soaked 
in  hot  vinegar  and  water  (equal  parts),  which  will  soften 
and  in  time  dissolve  the  nits,  and  carefully  combed  with 
a  fine  comb.  The  process  is  repeated  until  the  pediculi 
have  disappeared.  In  a  hospital  ward  it  is  usually  desir- 
able to  use  a  head  lotion  and  thorough  combing  daily. 
Tincture  of  larkspur  is  the  lotion  generally  preferred. 

Where  pediculi  are  found  on  the  hair  of  the  body,  a  daily 
bath  of  soap  and  water,  followed  by  a  sponging  with  bi- 
chlorid of  mercury  1  :  2000  and  tincture  of  larkspur  applied 


BEDS   AND    BED-MAKING  87 

to  the  affected  parts,  shaving  where  necessary.  The 
clothes  of  such  patients  are  best  destroyed,  but  where 
this  is  impracticable,  they  may  be  disinfected  with  the 
fumes  of  sulphur,  or  baked  in  an  autoclave  and  subse- 
quently washed. 

Lifting  a  Patient. — Lifting,  raising,  or  turning  a  patient 
is,  it  is  generally  conceded,  rather  a  question  of  skill  and 
knack  than  of  actual  strength,  and  the  doing  of  it  with  the 
greatest  degree  of  comfort  for  the  patient,  and  the  least 
physical  strain  for  the  lifter,  comes  only  with  repeated 
practice. 

For  this  lesson  nurses  should  work  in  pairs.  A  few 
words  of  preliminary  instruction  should  emphasize  some 
simple  rules  not  always  remembered. 

First:  Loosen  the  bed-clothes  in  the  first  place,  so  that 
3'our  movements  may  be  unhampered,  and  arrange  them 
so  that  the  patient  will  not  become  uncovered. 

Second:  Work  in  unison. 

Third:  Use  the  whole  hand,  not  just  the  fingers. 

Fourth:  Avoid  all  jerking,  pulling,  and  ineffectual 
movement;  each  movement  should  accomplish  its  definite 
purpose. 

Fifth:  Bend  from  the  knees  and  hips,  not  from  the  back. 

To  Turn. — One  nurse  is  usually  sufficient  for  this  process. 
Stand  on  the  side  to  which  the  patient  is  to  turn.  Reach 
across  the  patient,  and  place  the  open  hands,  firmly,  one 
behind  the  shoulders  and  one  over  the  pelvis  about  the 
end  of  the  spine,  and  draw  the  patient  toward  you.  In 
cases  of  extreme  weakness  the  head  must  be  supported 
by  a  second  nurse. 

Where  a  patient  is  unusually  heavy  and  helpless,  a 
draw-sheet  or  stout  towel  may  be  slipped  under  the 
shoulders  and  under  the  pelvis  respectively,  the  further 
ends  of  which  are  then  grasped  and  drawn  by  the  nurse  to- 
ward her,  thus  at  the  same  time  rolling  the  patient  into 
the  required  position. 

To  Lift  in  Bed. — First:  Stand  on  either  side  of  the  bed 
about  the  level  of  the  patient's  shoulder. 

Second:  Place  one  arm  below  the  patient's  shoulders 
and  grasp  him  as  far  toward  the  opposite  axilla  as  can  be 


05  PRACTICAL   METHODS 

done  easily  (to  strain  will  produce  a  jerking  movement); 
pass  the  other  hand  and  arm  as  far  as  is  easily  done  in 
the  same  way  below  the  pelvis  toward  the  opposite  hip. 

Third:  Then  lift  simultaneously. 

Patients  may  likewise  be  lifted  as  well  as  turned  by 
the  help  of  a  draw-sheet  or  towel  placed  under  the  pelvis 
and  under  the  shoulders.  Each  nurse  grasps  the  ends  of 
the  draw-sheet  on  her  side,  and  working  in  unison  with  the 
opposite  nurse,  lifts  the  patient  slightly  from  the  bed  and 
lays  him  down  in  the  required  position.  Where  even  such 
slight  movement  is  accompanied  by  risk,  lifting  may  be 
accomplished  with  the  minimum  amount  of  movement 
by  loosening  the  under  sheet,  rolling  each  side  toward  the 
patient,  grasping  it  from  opposite  sides  on  a  level  with  the 
shoulder  and  just  below  the  pelvis,  and  lifting  the  patient 
with  the  sheet. 

To  Raise  a  Patient  into  a  Sitting  Posture. — One  nurse  is 
generally  sufficient.  Stand  beside  the  patient's  right 
shoulder,  pass  the  left  arm  over  the  shoulder  to  the  oppo- 
site axilla,  and  the  right  under  the  near  arm  below  the 
shoulder,  toward  the  middle  of  the  back;  direct  the  patient 
to  pass  his  right  arm  under  the  nurse's  right,  and  bring 
his  hand  over  on  to  her  shoulder,  and  the  raising,  even  of  a 
heavy  patient,  is  accomplished  very  easily. 

Lifting  may  also  be  made  more  easy  when  the  patient 
can  help  himself  slightly  in  this  way.  The  amateur  method, 
which  is  to  direct  the  patient  to  place  his  arms  round  the 
nurse's  neck,  hampers  her  movements  and  leaves  both  the 
nurse  and  patient  breathless.  In  many  hospitals  each  bed 
is  provided  with  a  pulley  attached  to  a  strong  iron  bracket 
or  hanging  from  the  ceiling.  By  holding  on  to  this  a 
patient  can,  with  very  little  exertion  on  his  part,  immensely 
help  the  nurse  in  lifting. 

To  Lift  From  the  Bed. — For  this  purpose  the  nurses  must 
both  stand  on  the  same  side  of  the  bed. 

When  the  patient  can  sit  up,  he  can  be  placed  sitting 
at  the  edge  of  the  bed.  The  nurses  pass  their  arms  be- 
hind the  shoulders  and  below  the  pelvis,  and  grasp  each 
other's  arms  firmly.  The  patient  helps  by  placing  his 
hand  on  the  shoulders  of  the  nurses — either  the  nearest 


BEDS   AND    BED-MAKING  89 

shoulder  or  the  further,  according  to  the  size  of  the  patient. 
In  this  way  a  patient  may  be  carried  some  distance  with 
little  effort.  It  is  important  to  remember  that,  in  carrying, 
the  bearers  keep  step  out  of  step,  that  is  to  say,  instead  of 
both  right  and  both  left  feet  stepping  together,  the  right 
keeps  time  with  the  opposite  left,  otherwise  the  patient 
will  be  jerked. 

To  return  a  patient  to  bed,  first  set  him  on  the  side  of  the 
bed,  then  lift  his  feet  on  to  the  bed,  and  finally  lower  his 
shoulders. 

The  method  of  lifting  a  recumbent  patient  from  his  bed 
has  already  been  described  in  the  directions  on  changing 
the  mattress. 

In  carrying  a  patient  on  a  stretcher,  he  should  be  carried 
feet  foremost;  again  it  is  necessary  to  remember  to  walk 
moving  the  opposite  feet  simultaneously  in  order  to  avoid 
jerking.  The  reason  for  this  is  very  simply  demonstrated 
by  getting  two  nurses  to  carry  between  them  a  bucket  full 
of  water.  If  they  keep  step  in  the  usual  way,  the  water 
will  be  spilt. 

To  Arrange  a  Patient  in  Bed. — When  a  patient  is  too 
weak  to  support  himself  in  the  sitting  posture,  or  in  those 
pitiful  cases  where  no  other  posture  is  possible,  some 
ingenuity  is  required  to  make  the  position  a  comfortable 
one,  and  to  prevent  the  patient  slipping.  While  there 
may  be  fifty  ways  of  arranging  the  pillows  to  suit  one 
case,  some  simple  methods  of  keeping  a  patient  comfort- 
able in  an  upright  position  may  be  demonstrated. 

A  bed-rest  is  more  comfortable  than  a  pile  of  pillows,  as 
it  better  retains  its  shape  and  position.  Bed-rests  come 
in  many  devices,  from  the  simple  wooden  frame  filled 
in  with  crossed  pieces  of  webbing  and  attached  in  a  slant- 
ing position  to  the  railing  at  the  head  of  the  bed,  to  the 
upholstered  variety,  something  like  the  top  of  an  arm- 
chair, which  can  be  raised  and  lowered  from  a  graduated 
frame.  Those  used  in  hospitals  should  be  capable  of  being 
easily  cleaned  and  disinfected.  On  the  bed-rest  a 
couple  of  pillows  at  least  will  be  needed — one  upright  for 
the  back,  and  one  across  for  the  head  and  shoulders.  A 
tiny  one,  placed  just  below  the  back  of  the  head,  is  a  veryv 


90  PRACTICAL   METHODS 

comfortable  addition.  Small  pillows  should  be  arranged 
under  either  elbow. 

To  maintain  this  position  many  devices  have  been 
tried,  none  of  which  are  at  all  times  successful. 

First:  A  pillow  tied  into  a  firm  roll  may  be  placed  below 
the  pelvis  and  kept  in  place  by  passing  a  bandage  through 
the  roll  and  tying  the  ends  to  the  bed-frame. 

Second:  A  pillow  filled  with  sand  may  be  placed  just 
below  the  pelvis,  and,  as  it  retains  its  shape  and  position, 


Fig.  7. — Showing  foot-sling,  for  supporting  patient  in  the  upright 

position. 

is  found  much  more  comfortable  than  it  sounds.  A 
second  sand-pillow  should  be  placed  for  the  feet  to  press 
against. 

Third:  The  foot-sling  may  be  used  (Fig.  7).  This  con- 
sists of  a  sheet  folded  four  or  six  times  lengthwise,  with  a 
long  piece  of  tape  tied  firmly  to  each  end.  The  sheet  is 
passed  across  the  bed  and  tied  by  the  tape  on  either  side 
to  the  railing  at  the  head  of  the  bed  at  the  right  distance, 
so  that  the  patient's  feet  may  rest  firmly  against  the  sling. 
A  small,  well-filled  pillow  is  placed  below  the  knees.  This 


HEDS   AMD    BED-MAKING  91 

method  is  usually  the  most  reliable.  The  sling  may  be 
modified  by  wrapping  in  the  sheet,  where  the  feet  would 
rest,  a  small  pillow  or  a  small  pillow  made  more  stiff  by 
being  attached  to  a  small  piece  of  board. 

Where  the  upright  position  is  maintained,  the  skin  over 
the  coccyx  will  require  the  greatest  care.  The  patient 
may  be  nursed  entirely  on  an  air-  or  water-bed,  or  press- 
ure may  be  lessened  by  using  an  air-  or  water-ring  cushion, 
not  too  much  inflated.  Where  this  is  done,  the  patient 
may  complain  of  feeling  his  feet  too  low,  a  very  fatiguing 
sensation.  This  can  be  remedied  by  raising  the  lo\ver  end 
of  the  bed  on  small  blocks,  or  by  placing  a  blanket  folded 
into  several  thicknesses  below  the  lower  half  of  the 
mattress. 

The  above  demonstrations  may  constitute  the  practical 
lessons  given  to  the  pupil  nurses  in  their  first  two  weeks, 
and  must,  to  insure  perfection,  be  constantly  practised 
during  the  junior  and  intermediate  years.  Quickness 
should  not  be  enforced  at  first:  it  is  too  apt  to  mean 
scamped  work.  Quickness  should  follow  when  practice 
has  made  perfect. 

From  the  earliest  days  pupils  should  be  taught  quiet 
and  dignified  behavior  while  at  their  work,  and  habits  of 
consideration  and  kindness  toward  their  patients.  No 
conversation  on  personal  topics  should  be  allowed  in  the 
wards,  and  no  raised  voices  or  noisy  movements. 


CHAPTER  II 

» 

BATHS  AND  PACKS 

General  Rules — Hot  Tub-bath  for  Cleansing,  to  Induce  Perspira- 
tion, to  Relieve  Convulsions — Sitz-bath — Foot-bath — Constant  Im- 
mersion— Local  Baths — Cold  Tub-bath—Brandt  Bath — Medicated 
Baths— Hot  Pack— Dry  Pack— Hot-air  Bath— Vapor  Bath— Elec- 
tric-light Bath — Cold  Sponge — Drip  Sponge— Affusion — Ice-rub — 
Ice  Cradling — Paddling— Cold  Pack. 

A  BATH,  strictly  speaking,  is  a  means  by  which  the  body 
is  immersed,  usually  in  water,  though  in  special  conditions 
other  media,  such  as  vapor,  hot  air,  or  the  mud  or  sand  of 
special  districts,  is  used.  The  bath  may  be  general, 
including  the  entire  body,  or  local,  as  when  a  limb  only  is 
immersed.  The  hot  bath  with  a  good  simple  soap  is  the 
best  means  of  keeping  the  skin  in  a  clean  and  active  con- 
dition; the  cold  plunge  bath,  one  of  the  best  tonics  to  the 
skin  and  circulation — by  stimulating  the  circulation,  the 
processes  of  elimination  and  metabolism  are  also  in- 
creased. 

The  bath  is  also  a  valuable  therapeutic  agent,  and  as 
such  is  employed  at  different  temperatures  in  a  large 
variety  of  circumstances.  The  hot  bath  is  used  to  induce 
perspiration,  to  relax  local  spasms  or  general  convulsions, 
to  restore  bodily  warmth,  to  relieve  pain  and  inflamma- 
tion, to  relieve  retention  of  urine,  as  a  sedative  in  some 
nervous  conditions,  and  as  a  stimulant  in  cases  of  collapse. 
It  is  a  simple  agent  in  relieving  fatigue  and  soothing  ner- 
vous irritability,  and,  in  the  milder  forms  of  insomnia,  may 
induce  sleep.  The  cold  tub-bath  is  used  to  reduce  temper- 
ature, to  stimulate  a  sluggish  circulation,  to  reduce  inflam- 
mation, and  as  a  tonic,  either  to  invigorate  the  system,  or 
in  the  case  of  some  nervous  conditions. 

For  therapeutic  purposes  medicinal  agents  are  frequently 
combined  with  the  bath,  as,  for  example,  the  hot  mustard 
bath,  for  purposes  of  stimulation;  the  mercurial  vapor 
92 


BATHS    AND    PACKS  93 

bath   in  the  treatment  of  syphilis;  the  tub-bath  with 
sulphur,  bran,  etc.,  in  the  treatment  of  some  skin  affections. 
The  temperatures  usually  ordered  for  the  bath  may  be 
divided  as  follows: 

Cold  bath,  40°-70°  F. 
Cool  bath,  70°-80°  F. 
Tepid  bath,  80°-90°  F. 
Warm  bath,  90°-100°  F. 
Hot  bath,  100°-110°  F. 

In  giving  any  bath  certain  general  conditions  must  be 
observed. 

A  bath  is  not  given  immediately  after  food.  One  hour 
after  a  light  meal  and  two  hours  after  a  full  dinner 
should  be  allowed  to  elapse.  The  reason  for  this  is  that 
the  bath,  by  causing  the  superficial  blood-vessels  of  the 
body  to  dilate  and  become  filled  with  blood,  diverts  the 
blood-supply  from  the  digestive  organs,  which,  during 
digestion,  require  an  increased  supply  of  blood  for  their 
work.  In  consequence  we  get  the  condition  of  arrested 
digestion,  with  the  characteristic  symptoms  of  acute  head- 
ache, local  pain,  nausea,  and  vomiting. 

No  patient  should  remain  in  hot  water  long  enough  to 
become  exhausted.  Five  or  ten  minutes  is  sufficient  for 
a  cleansing  bath.  A  nurse  should  understand  clearly  the 
effect  to  be  desired  in  giving  the  bath,  the  most  prompt  and 
exact  manner  of  giving  it,  the  symptoms,  toward  and  un- 
toward, to  be  watched  for;  she  should  also  realize  the 
importance  of  keeping  closely  to  orders  concerning  the 
temperature  of  the  bath  and  the  length  of  time  for  which 
the  treatment  is  to  be  continued. 

The  bath-room  should  be  well  ventilated,  free  from 
draughts,  and  kept  at  a  temperature  of  60°  to  65°  F.  A 
higher  temperature  is  not  advisable,  the  bath-room  be- 
coming rapidly  overheated  while  giving  a  hot  bath. 
With  hospital  patients  three  rules  should  be  strictly' 
enforced,  and  may  with  advantage  be  posted  in  a  promi- 
nent place  in  the  bath-room : 

1.  Every  patient  in  taking  a  bath  must  be  accompanied 
by  a  nurse  (or  an  orderly) ,  unless  by  a  special  written  order 


94  J5ATHS    AND    PACKS 

to  the  contrary,  in  which  case  the  door  must  never  be 
locked. 

2.  In  every  case  the  temperature  of  the  bath  must  be 
taken  with  the  bath  thermometer. 

3.  In  drawing  a  bath,  some  cold  water  must  always  be 
run  in  first.     The  latter  rule  is  chiefly  in  order  to  preserve 
the  bath-tub  from  abuse.     The  boiling  hot  water  found  in 
institutions  is  sufficient  to  crack  a  glass  or  porcelain  tub 
or  to  destroy  the  paint  of  a  painted  wood  or  metal  tub. 
In  time  it  will  also  spoil  the  polished  surface  of  an  enameled 
iron  tub,  which  otherwise  best  resists  it.     It  is  also  a  wise 
precaution  in  another  sense.     Cases  are  on  record  where, 
the  hot  water  only  in  the  bath,  a  child  has  accidentally 
been  placed  in  the  water  and  scalded. 

The  Cleansing  Bath. — On  admission  to  a  hospital  a 
patient,  if  he  is  in  appropriate  bodily  condition,  is  usually 
ordered  a  tub-bath.  Opinion  differs  greatly  as  to  what 
constitutes  an  appropriate  bodily  condition.  Some  doctors 
prefer  the  bed-bath  if  the  patient's  temperature  is  over 
100°  F.;  others  consider  the  tub-bath  beneficial  in  almost 
any  circumstances  where  the  patient's  bodily  strength 
admits  of  the  necessary  amount  of  movement.  In  the 
case  of  sick  children  a  tub-bath  may,  in  the  majority 
of  circumstances,  be  safely  given,  as  by  careful  lifting  and 
carrying  they  can  be  saved  all  exertion. 

While  the  bed-bath  may  remove  as  much  perceptible 
dirt  as  the  tub-bath,  it  has  not  the  same  beneficent  effect 
on  the  system.  The  skin  is  one  of  the  most  important 
excretory  organs  of  the  body.  If  not  cared  for,  the  pores, 
which  are  the  openings  of  the  ducts,  become  blocked  with 
dust  and  dried  perspiration,  thereby  lessening  the  func- 
tional activity  of  the  skin.  The  hot  tub-bath  not  only 
frees  the  pores  of  any  superficial  accumulation,  but,  dilat- 
ing the  surface  blood-vessels,  brings  more  blood  to  the 
skin,  stimulating  the  sweat-glands  to  greater  activity, 
and  thus  clearing  the  pores  and  ridding  the  body  of  some 
of  the  poisonous  products  of  oxidation. 

In  giving  a  tub-bath  fill  the  bath  half  full  of  water  at  a 
temperature  of  100°  F.,  which  may  be  raised  to  105°  F. 
after  the  patient  is  in.  Change  the  water  if  it  becomes 


TO    INDUCE    PERSPIRATION  95 

dirty  before  the  washing  is  over.  Borax,  washing-soda, 
or  a  small  quantity  of  aqua  ammonia  may  be  added  to 
the  water  if  the  skin  is  very  dirty  or  the  water  hard. 

Before  beginning,  cut  the  nails  close  and  pin  long  hair 
on  the  top  of  the  head.  If  it  is  necessary  to  wash  the  hair 
at  the  same  time,  it  is  better  for  a  woman  patient  to  do  so 
first  over  a  basin.  A  man  or  child  can  have  the  hair 
washed  conveniently  in  the  tub. 

Frequently  with  ward  patients  the  admission  bath  is 
not  sufficient  to  cleanse  thoroughly  susceptible  portions 
of  the  body,  such  as  the  soles  of  the  feet  or  the  palms  of 
the  hands.  Where  the  dirt  is  ingrained  and  the  epidermis 
hard  and  thickened,  it  is  best  to  soften  the  skin  by  envel- 
oping the  parts  in  a  soap  or  flaxseed  poultice,  if  the  general 
condition  of  the  patient  permits.  The  hands  may  be 
frequently  soaked  in  hot  water  and  washing-soda  and 
scrubbed  with  nail-brush  and  soap.  No  nurse  should  feel 
satisfied  until  every  patient  in  her  charge  is  spotlessly 
clean,  but  she  will  frequently  have  to  remember  to  pro- 
ceed with  tact. 

After  the  bath  the  patient  should  be  thoroughly  dried 
with  warm  towels,  warmly  wrapped,  and  returned  quickly 
to  bed.  The  effect  of  the  bath  must  be  noted,  especially 
such  symptoms  as  shivering,  faintness,  undue  fatigue,  or 
exhaustion.  The  first  may  be  avoided  by  having  a  hot- 
water  bag  in  readiness  in  the  bed;  faintness  is  relieved  by 
fresh  air  and  lying  still  without  the  pillows;  while  for 
any  signs  of  exhaustion  a  glass  of  hot  milk  is  a  good 
restorative. 

To  Induce  Perspiration  (Fig.  8). — For  this  purpose  the 
bath  is  filled  half  full  of  water  at  100°  F.,  and  the  tempera- 
ture brought  to  110°  F.  or  higher  if  well  borne  while  the  pa- 
tient is  in  the  bath.  Two  blankets  cover  the  bath  and  are 
pinned  together  at  the  patient's  neck,  thus  leaving  his  head 
only  exposed.  The  blankets  are  prevented  from  sagging 
by  a  couple  of  boards  arranged  across  the  bath-tub.  Cold 
sponges  or  an  ice-bag  are  kept  on  the  patient's  head,  and 
the  process  is  helped  if,  at  the  same  time,  he  drinks  freely 
either  cold  water,  Vichy,  etc.,  or  hot  weak  tea.  The  pulse 
must  be  taken  at  the  carotid  or  in  front  of  the  ear,  and  the 


96 


BATHS   AND   PACKS 


patient  removed  if  it  becomes  soft,  compressible,  or  in- 
termittent. In  all  cases  where  we  apply  extreme  heat  in 
this  manner  or  by  similar  methods  to  the  body,  cold  is  applied 
at  the  same  time  to  the  head  in  order  to  prevent  what  is 
known  familiarly  as  a  "  rush  of  blood  to  the  head,"  with 
the  symptoms  of  giddiness  and  faintness.  If  faintness 
should  occur,  the  patient  is  removed  immediately  and  made 
to  lie  flat  without  pillows.  A  stimulant,  such  as  aromatic 
spirits  of  ammonia  (30  minims  in  water),  is  frequently 
ordered  for  such  an  emergency. 


Fig.  8. — Tub-bath  to  induce  sweating. 

From  four  to  seven  minutes  is  usually  the  length  of  time 
ordered  for  such  a  sweat-bath.  If  it  is  desirable  that  the 
sweating  should  continue,  the  patient  is  quickly  wiped, 
wrapped  in  a  hot  blanket,  and  put  to  bed  surrounded  with 
hot-water  bottles,  covered  with  several  blankets  tucked 
closely,  especially  round  the  back,  and  again  induced  to 
drink.  The  ice-bag  is  kept  on  his  head.  He  may  be  kept 
thus  for  an  hour,  close  watch  being  kept  on  the  pulse. 
Finally  he  is  rubbed,  under  a  dry  blanket,  first  with  hot 
towels  and  then  with  alcohol,  and  the  ordinary  clothes, 
well  warmed,  replaced.  This  final  process  is  observed  after  all 
baths  that  have  for  their  purpose  the  inducing  of  perspiration. 


HOT   SITZ-BATH  97 

This  simple  form  of  bath  is  ordered  when  the  patient 
is  in  sufficiently  good  bodily  condition  to  be  moved  from 
his  bed,  as  in  the  chronic  forms  of  kidney  disease,  to  break 
up  a  cold,  etc.  In  acute  illness  other  methods  are  used 
which  will  be  discussed  presently. 

To  Relieve  General  Convulsions. — For  this  purpose  the 
patient,  usually  in  a  completely  unconscious  state  at  the 
time,  lies  immersed  in  the  water,  his  head  supported  on  the 
left  arm  of  the  nurse,  while  with  her  right  hand  she  con- 
stantly sponges  the  head  with  cold  water.  The  water 
is  prepared  at  100°  F.  and  brought  to  105°  F.  when  the 
patient  has  been  in  the  water  a  few  moments.  Owing  to 
the  unconscious  condition  of  the  patient  it  is  not  safe  to 
use  a  higher  temperature.  Frequently  the  orders  are  to 
keep  the  patient  in  the  water  until  the  convulsion  is  over 
and  the  body  relaxed.  At  other  times  the  order  may  be  for 
a  bath  lasting  five  to  ten  minutes,  or,  rarely,  longer,  and  re- 
peated at  intervals.  If  faintness  occurs,  evinced  by  sigh- 
ing respirations,  pallor  of  the  lips,  and  a  pulse  becoming 
soft,  compressible,  and  intermittent,  the  patient  is  re- 
moved at  once  and  replaced  in  bed,  when  the  symptoms 
will  usually  pass.  Stimulants  are  not  generally  ordered 
in  these  cases. 

After  the  bath  the  patient  is  dried,  the  shirt  replaced, 
and  he  is  put  back  to  bed  to  rest  quietly.  If  the  bath  is  to 
be  repeated,  the  shirt  may  be  omitted,  and  the  patient 
rolled  in  a  light  blanket,  in  which  he  can  be  carried  to  the 
bath,  it  being  an  important  consideration  to  carry  out  the 
treatment  with  as  little  disturbance  as  possible  to  the 
already  irritated  nerve-centers. 

If  such  a  bath  is  used  during  an  attack  of  croup  or  for 
convulsions  caused  by  teething,  the  baby  is  usually  kept  in 
the  bath  until  relaxation  is  complete. 

The  hot  sitz-bath  is  used  to  relieve  local  inflammations, 
such  as  pelvic  cellulitis,  or  to  relax  the  sphincter  of  the 
bladder  and  so  overcome  retention  of  urine.  The  tem- 
perature begins  at  100°  F.,  rising  gradually  as  high  as  can 
be  borne.  The  patient,  sitting  in  the  bath,  has  the  body 
immersed  in  water  from  the  upper  part  of  the  thighs  to 
the  waist.  The  legs  are  wrapped  in  a  blanket,  and  a  second 


98  BATHS  AND    PACKS 

blanket,  pinned  round  the  neck,  is  arranged  to  cover 
both  bath  and  patient.  The  bath  lasts  ten  to  twenty 
minutes,  or  if  for  retention  of  urine,  until  the  condition 
is  relieved. 

The  hot  foot-bath  is  valuable  in  restoring  vitality,  in 
breaking  up  a  cold,  in  relieving  headache,  and  sometimes 
as  a  remedy  for  insomnia.  In  the  latter  cases  it  acts  by 
drawing  the  blood  from  the  brain  to  the  extremities,  thus 
inducing  a  temporary  anemia  of  the  brain.  The  bath  is 
prepared  at  100°  F.,  and  raised  as  high  as  can  be  borne 
without  faintness.  The  patient  should  recline  in  a  chair 
comfortably  wrapped,  with  a  light  blanket  folded  over  the 
legs  and  bath.  If  the  patient  is  in  bed,  the  bed-clothes 
are  turned  back  and  the  bed  protected  by  a  rubber  sheet. 
The  bath  is  placed  conveniently,  and  a  light  blanket  kept 
over  the  bath  and  limbs  during  the  process. 

The  tank  or  constant  immersion  treatment  may  be 
ordered  for  special  cases.  At  one  time  it  was  in  vogue  for 
typhoid-fever  patients;  more  generally  it  is  used  for  cases 
with  large  external  wounds,  such  as  extensive  burns  or 
scalds  or  large  infected  bed-sores. 

The  bath  used  is  a  portable,  full-sized  bath-tub  on 
castors,  and  should  be  provided  with  a  stop-'cock  in  order 
to  empty  it  easily.  If  it  is  without  a  stop-cock,  the  con- 
tents may  be  siphoned  off.  To  do  so,  attach  a  funnel  to 
a  piece  of  uncollapsible  rubber  tubing,  place  the  funnel 
in  the  bath,  and  lower  the  other  end  of  the  tube  over  a 
bucket.  Start  by  filling  the  tube  with  water  from  the  fun- 
nel end,  keeping  the  lower  end  pinched  until  the  funnel  is 
inverted  in  the  bath  water.  A  hammock  is  made  of 
several  strips  of  wide  webbing  with  a  ring  sewn  at  either 
end;  these  are  attached,  usually  by  strong  hooks,  to  the 
outside  of  the  rim  of  the  bath-tub.  If  there  are  no  hooks 
on  the  tub,  a  stout  cord  can  be  run  through  the  rings  and 
firmly  tied  under  the  rim  of  the  tub.  The  cord  must  be 
knotted  at  each  ring  to  prevent  the  strips  slipping  to- 
gether. The  head  is  supported  by  a  rubber  ring  cushion, 
also  attached  in  the  same  way  to  the  tub.  A  couple  of 
boards  are  placed  across  the  tub  to  prevent  the  coverings 
sagging,  and  the  whole  is  covered  with  a  rubber  sheet  and 


LOCAL   BATHS  99 

blankets.  If  the  ordinary  bed-clothes  are  added,  the 
tank  can  look  as  neat  and  comfortable  as  the  ordinary  bed. 

A  thermometer  must  be  kept  suspended  and  an  even 
temperature  maintained— usually  the  temperature  ordered 
is  from  100°  to  102°  F.  Once  a  day  the  patient  is  moved 
on  to  a  mattress  and  the  bath  emptied,  cleaned,  rinsed  with 
a  disinfectant,  and  refilled.  At  this  time  the  daily  evacu- 
ation of  the  bowels  should  take  place.  If  there  is  no  im- 
pulse for  movement,  a  soap  or  glycerin  suppository  may 
have  the  desired  result.  During  this  time  the  wounds  are 
either  dusted  with  sterile  boric  powder  (2  per  cent.)  or 
covered  with  wet  sterile  gauze.  Such  treatment  is  found 
comfortable  and  peculiarly  satisfactory  in  cases  where 
large  painful  daily  dressings  can  be  thus  avoided,  or  when 
it  is  impossible  otherwise  to  relieve  painful  parts  from 
constant  pressure.  A  mild  antiseptic  is  usually  added  to 
the  water,  which  should,  wherever  practical,  be  sterile. 
Boric  acid,  about  1  per  cent.,  i.  e.,  about  one  ounce  of  the 
powder  for  each  gallon  of  water,  is  generally  preferred. 
A  full-sized  tub-bath  half  full  usually  contains  10  to  15 
gallons  of  water. 

Almost  the  only  disadvantage  of  such  treatment  is  the 
disturbance  unavoidable  in  moving  the  patient  each  time 
it  is  necessary  to  give  the  bed-pan.  In  a  case  of  typhoid 
fever,  where  a  minimum  amount  of  movement  is  an  es- 
sential part  of  the  treatment,  this  is  a  decided  drawback. 
Where  there  is  loss  of  control  of  either  bladder  or  rectum, 
the  tank  is  not  an  appropriate  treatment. 

Local  baths,  or  constant  immersion,  are  also  frequently 
ordered  for  septic  wounds  of  the  limbs.  Pans  of  suitable 
size  and  shape  are  sold  for  this  purpose  by  surgical  instru- 
ment-makers, but  are  expensive,  except  where  they  are  to 
be  frequently  used,  as  in  hospital  wards.  For  a  forearm 
a  fish-kettle  makes  a  good  substitute,  and  for  a  leg  a  long 
box,  such  as  is  used  by  florists  for  flower-stands,  may  be 
adapted.  The  hammocks  to  support  the  limbs  in  a  com- 
fortable position  are  made  of  strips  of  webbing  two  inches 
wide,  each  strip  with  its  ends  sewn  together  and  made 
long  enough  to  go  round  the  vessel  and  dip  down  into  the 
bath  as  low  as  is  wanted.  The  weight  of  the  limb  is  usually 


100  BATHS   AND   PACKS 

enough  to  keep  the  strips  in  place;  if  not,  a  tape  can  be 
knotted  at  intervals  round  each  strip  and  tied  securely 
round  the  rim  of  the  vessel. 

The  arm  bath  should  be  placed  on  a  table  beside  the 
bed,  and  the  patient  well  supported  with  many  pillows; 
the  constrained  position  is  always  a  tiring  one.  For  a 
leg  bath  ingenuity  is  required  to  place  the  bath  at  a  suffi- 
ciently low  level.  It  may  be  placed  outside  the  bed,  on 
high  stools,  and  the  patient  brought  to  the  edge  of  the  bed; 
or  a  mattress  in  two  parts  may  be  used  and  the  lower  half 
removed.  The  sound  limb  can  be  brought  to  the  level 
of  the  body  by  adjusting  folded  blankets  and  pillows. 
Usually  boric  acid,  1  to  2  per  cent,  in  sterile  water,  is 
used,  and  the  temperature  maintained  at  100°  F.  The 
local  bath  is  covered  with  a  rubber  sheet  and  small  blanket. 
The  solution  is  changed  every  six  hours,  and  once  a  day  the 
bath  should  be  thoroughly  scoured  and  disinfected.  Where 
it  is  desired  to  keep  the  limb  absolutely  immovable,  the 
bath  must  be  emptied  by  siphonage. 

The  complete  tub-bath  of  cold  water  for  the  treatment 
of  fever  cases  was  first  advocated  by  a  German  doctor 
named  Brandt  as  far  back  as  1861;  the  method  is,  in  con- 
sequence, often  referred  to  as  the  Brandt  bath.  Within 
the  last  twenty  years  it  has  become  universally  popular, 
though  possibly  somewhat  less  so  at  the  date  of  writing. 
It  has  as  its  object  to  reduce  the  temperature  and  to 
relieve  the  cerebral  symptoms.  It  is  also  claimed  that 
through  stimulation  of  the  circulation  the  natural  processes 
of  metabolism  and  elimination  are  increased  and  the  skin 
stimulated  to  greater  activity.  It  may  frequently  be 
observed  that  after  the  bath  urine  is  more  freely  excreted. 
Its  use  is  most  generally  in  the  treatment  of  typhoid  fever, 
the  mortality  of  which  the  use  of  the  Brandt  bath  is  con- 
sidered greatly  to  have  reduced. 

The  bath  must  be  given  with  the  minimum  amount 
of  disturbance  to  the  patient.  A  bath-tub  on  castors,  pro- 
vided usually  with  stop-cock  for  emptying,  is  brought 
to  the  bedside,  half  full  of  water  of  the  required  tempera- 
ture. Some  doctors  have  the  water  cold  to  begin  with, 
others  begin  at  90°  F.  and  rapidly  lower  the  temperature 


COMPLETE    TUB-BATH    OF   COLD    WATER 


101 


to  60°  F.  by  adding  lumps  of  ice  after  the  patient  is  in 
the  tub.  The  time  ordered  is  usually  five,  ten,  or  fifteen 
minutes,  and  the  treatment  is  carried  out  every  three, 
four,  or  six  hours  if  the  patient's  temperature  rises  above 
a  certain  point.  Usually  a  temperature  of  102.5°  F.  or 
103°  F.  is  considered  an  indication  for  the  bath. 

The  bath  in  readiness,  the  patient  has  a  wide  towel 
pinned  round  the  loins  and  secured  between  the  legs  with 
a  safety-pin,  and  the  shirt  removed.  The  limbs  and  chest 
should  be  free  of  clothing.  In  hospitals  an  appropriate 
stretcher  is  usually  found,  made  of  strips  of  webbing  about 
three  inches  wide,  attached  about  three  inches  apart  to  a 


Fig.  9. — Tub-bath  for  immersion,  and  bed  arranged  for  return  of 

patient. 

double  strip  of  canvas  or  stout  ticking  through  which  the 
stretcher  poles  are  run;  the  stretchers  are  provided  with 
rings  by  which  they  are  attached  to  hooks  on  the  outside 
of  the  tub.  The  stretcher  is  rolled  below  the  patient  in  the 
same  way  that  a  sheet  is  changed,  the  poles  are  adjusted, 
and  he  is  lifted  and  lowered  into  the  bath  on  the  stretcher. 
The  bath  over,  a  dry  sheet  is  laid  across  the  bath,  the 
loin  towel  unpinned  under  cover  and  left  in  the  water, 


102  BATHS   AND    PACKS 

the  stretcher  raised,  the  superfluous  water  allowed  for  a 
moment  or  two  to  drip  away,  and  the  patient  lifted  back 
to  bed,  covered  with  the  dry  sheet. 

Where  there  is  no  such  stretcher,  a  stout  hammock 
makes  a  good  substitute,  or  the  patient  may  be  lifted  in 
his  sheet;  the  sheet,  however,  must  be  left  in  the  water 
after  the  bath  and  the  patient  lifted  inside  the  dry  sheet 
by  grasping  him  under  the  arms  below  the  pelvis  and  by 
the  feet. 

While  the  patient  is  in  the  bath  a  rubber  sheet  is  spread 
over  the  bed,  from  which  the  upper  clothes  are  removed: 
a  single  blanket  and  a  sheet  are  folded  in  readiness  over  the 
head  of  the  bed.  A  hot-water  bag  should  be  at  hand  ready 
filled  in  case  of  emergency. 

As  soon  as  the  patient  is  placed  on  the  bed  the  stretcher 
is  rolled  from  under  him  and  he  is  wrapped  loosely  in 
the  dry  sheet  and  gently  but  thoroughly  dabbed  until  the 
moisture  is  absorbed.  The  sheet  and  rubber  sheet  are 
then  removed,  and  the  patient  is  left  wrapped  in  a  light 
blanket  and  covered  with  a  sheet  until  all  signs  of  shiver- 
ing or  chilliness  have  disappeared,  when  the  shirt  is  re- 
placed, and  the  bed  arranged  in  the  usual  way.  If  the 
patient  should  fall  comfortably  asleep,  he  should  be  left 
until  he  wakes  without  disturbance. 

While  the  patient  is  in  the  bath,  constant  friction  with 
the  flat  of  the  hands  is  applied  to  the  limbs,  chest,  hips, 
and  shoulders.  The  pulse  must  be  closely  watched. 
At  first,  owing  to  contraction  of  the  superficial  arteries 
from  the  effect  of  the  cold,  the  pulse  will  feel  small  and 
hard,  and  from  the  nervous  shock  will  probably  be  in- 
creased in  rapidity.  It  should  gradually  improve,  be- 
coming stronger  and  slower  as  the  treatment  is  carried 
out  if  the  bath  is  having  the  desired  results. 

Symptoms  that  show  the  bath  is  having  an  injurious 
effect  are  cyanosis,  which  will  be  apparent  first  about  the 
lips,  a  weak,  soft,  intermittent  pulse,  and  uncontrollable 
shivering.  If  the  doctor  is  not  immediately  at  hand  to 
take  the  responsibility  of  the  bath  proceeding,  the  nurse 
is  usually  expected  to  return  the  patient  to  bed,  to  notify 
the  doctor  immediately,  and  not  to  repeat  the  bath  until 


COMPLETE   TUB-BATH   OF   COLD    WATER  103 

she  has  had  fresh  orders.  If  the  baths  are  to  be  continued, 
the  doctor  should  be  present  at  the  next  one.  Untoward 
symptoms  may  frequently  be  averted  by  the  administra- 
tion of  a  stimulant  immediately  before  the  bath;  the 
dose  may  also  be  divided  and  given  half  before  and  half 
immediately  after  a  bath. 

If  cyanosis  or  shivering  persist  after  the  bath  and  the 
pulse  remains  feeble  and  small  or  intermittent,  the  patient 
should  be  briskly  rubbed,  two  nurses  working  at  the  same 
time,  and  external  heat  applied  in  hot-water  bottles  ar- 
ranged at  the  feet  and  round  the  sides  of  the  patient. 
In  some  cases  it  is  necessary  to  place  the  feet  in  a  hot  foot- 
bath to  restore  the  bodily  warmth;  generally  an  order  is 
left  for  a  stimulant  to  be  administered  in  such  an  emergency. 
Cyanosis  and  shivering  sometimes  begin  after  the  patient 
is  returned  to  bed.  In  these  circumstances  also  the  doctor 
should  always  be  notified,  and  his  orders  repeated  before 
the  next  bath  is  given. 

Before,  and  immediately  after,  each  bath  the  temper- 
ature, pulse,  and  respiration  are  taken  and  noted  in  writing. 
Half  an  hour  after  the  patient  is  returned  to  bed  this  is 
repeated  and  again  noted.  A  drop  of  over  one  and  one- 
half  degrees  is  not  generally  desirable,  and  should  be  at 
once  reported.  Should  the  patient  be  sleeping,  usually  the 
taking  of  the  temperature  is  omitted  and  a  record  of  pulse 
and  respiration  only  made.  At  the  same  time  the  temper- 
ature to  which  the  water  was  reduced,  the  length  of  time 
the  patient  was  in  the  bath,  and  any  symptoms,  toward 
or  untoward,  that  were  apparent  should  be  noted  accu- 
rately in  writing. 

From  the  gravity  of  the  condition,  the  manner  in  which 
the  cold  bath  is  given  in  a  typhoid-fever  case  is  of  special 
importance.  No  nurse  should  undertake  the  responsibil- 
ity of  giving  a  bath  to  an  adult  typhoid-fever  patient  alone. 

In  cases  of  typhoid  fever  it  is  considered  of  the  first  im- 
portance that  in  lifting  the  patient  the  body  should  be  kept 
rigid,  and  that  no  strain  whatever  should  be  thrown  on 
the  abdominal  muscles.  The  patient  must  not  exert 
himself  in  any  way.  Sudden  exertion,  especially  that 
causing  any  strain  or  movement  of  the  abdominal  muscles, 


104  BATHS   AND   PACKS 

might  cause  either  serious  internal  hemorrhage  from  one 
of  the  ulcers,  which  in  typhoid  fever  develop  on  the  walls 
of  the  intestines,  or  perforation  of  an  ulcer  through  the 
intestinal  wall  into  the  abdominal  cavity. 

Hemorrhage  and  perforation  are  the  most  dreaded  com- 
plications of  typhoid  fever.  The  first  symptoms  of  the 
occurrence  of  either  are  sudden  faintness,  pallor,  and 
rapidly  increasing  pulse-rate  and  sighing.  If  the  temper- 
ature is  taken,  it  is  found  to  have  fallen  probably  below 
normal.  Hemorrhage  is  further  evinced  by  the  passage 
later  of  blood-clots  from  the  rectum,  or  of  stools  turned 
a  dark  tarry  color  from  the  presence  of  altered  blood. 
In  perforation  the  patient  generally  also  complains  of 
acute  abdominal  pain  and  has  a  rigor  or  attack  of  shiver- 
ing, the  abdomen  quickly  becomes  inflated  with  gas,  a 
condition  known  as  tympanites,  and  rigid.  Either  of  these 
catastrophes  might  occur  as  a  consequence  of  giving  a 
Brandt  bath  carelessly.  Should  the  patient  evince  any 
such  symptoms  during  the  giving  of  the  bath,  he  must  be 
promptly  replaced  in  bed,  lying  flat  and  motionless  without 
a  pillow,  and  the  doctor  immediately  called.  All  treat- 
ment is,  in  the  mean  time,  stopped.  The  patient  may  be 
wiped  dry  without  turning  and  then  covered  only  with 
one  light  covering,  as  bodily  warmth  would  increase  the 
hemorrhage.  For  the  same  reason  no  drink  or  stimulant 
must  be  given.  (See  also  pp.  614  and  624.) 

Cold  baths  are  frequently  ordered  as  part  of  the  treat- 
ment of  nervous  cases.  In  ordering  such  treatment  doc- 
tors vary  greatly  in  their  methods,  and  all  orders  should 
be  minutely  written  down  and  accurately  carried  out. 
Some  order  one,  two,  or  three  plunges  in  a  bath-tub  nearly 
full  of  cold  water,  followed  by  brisk  rubbing;  in  other 
cases  the  patient  stands  with  the  feet  in  warm  or  hot  water 
and  the  cold  water  is  given  as  a  shower,  or  emptied  from  a 
bucket  suddenly  over  the  patient's  back.  Sea-salt  may 
be  ordered  to  be  added  to  the  water,  in  which  case  two 
pounds  of  Tidman  sea-salt  should  be  dissolved  in  boiling 
hot  water,  allowed  to  cool,  and  added  to  a  bath-tub  half 
full  of  water  (usually  reckoned  at  10  gallons).  If  a  salt- 
water bath  is  to  be  taken  hot,  the  sea-salt  is  added  when 


MEDICATED  TUB-BATHS  105 

the  bath  is  prepared.  During  the  salt-water  bath  and 
after  the  patient's  skin  should  receive  brisk  friction. 

Medicated  tub-baths  are  ordered  in  some  conditions. 
The  temperature  of  the  bath,  the  quantity  of  the  medica- 
ment, the  length  of  time  the  bath  is  to  be  taken,  are 
ordered  in  each  case.  Usually  the  bath  is  warm  enough  for 
comfort,  and  the  patient  remains  in  from  fifteen  to  thirty 
minutes.  The  bath-tub  must  be  carefully  cleaned  and 
disinfected  immediately  after  use.  The  bath  may  be 
reckoned  as  15  gallons  of  water. 

The  following  are  the  medicated  baths  most  commonly 
in  use: 

Starch  Bath. — Mix  half  a  pound  of  raw  starch  with 
cold  water  and  make  in  the  usual  way  by  adding  boiling 
water  until  thin.  Add  to  the  bath-tub.  Used  in  certain 
skin  diseases. 

Bran  Bath. — Tie  one  pound  of  bran  securely  in  a  loose 
bag  of  thin  muslin  and  place  in  a  large  deep  basin;  fill  the 
basin  with  boiling  water,  and  set  it  in  a  hot  place  for  half 
an  hour.  Press  the  moisture  from  the  bran  and  add  all  the 
fluid  to  the  bath.  Used  in  certain  skin  diseases. 

Alkaline  Bath. — Add  sufficient  bicarbonate  of  soda  to  a 
bath-tub  to  give  a  strong  alkaline  reaction.  Test  with  red 
litmus  paper  (p.  277).  If  litmus  paper  is  not  at  hand, 
the  bath  is  sufficiently  alkaline  when  the  water  has  a 
slippery  feeling.  Used  in  skin  diseases,  to  allay  itching 
in  irritable  eruptions,  such  as  urticaria,  and  occasionally 
ordered  for  cases  of  subacute  rheumatic  arthritis. 

Sulphur  Bath. — Sulphurated  potash  is  used,  it  being 
soluble  in  water.  Add  to  the  bath  in  the  proportion  of  half 
an  ounce  to  two  ounces  to  the  15-gallon  bath.  Used  in 
skin  diseases  and,  rarely,  for  purposes  of  general  stimula- 
tion. It  must  be  remembered  that  sulphur  discolors  metal 
substances. 

Stimulating  Bath. — Mustard  is  usually  employed.  Tie 
a  quarter  pound  of  table  mustard  in  a  muslin  bag  and 
place  in  a  basin  of  cold  water;  squeeze  the  bag  well  and 
add  the  water  to  the  bath  (15  gallons).  Used  at  a  tem- 
perature of  100°  to  105°  F.  to  restore  vitality,  especially 
in  infants  and  young  children.  The  mustard  foot-bath 


106  BATHS   AND   PACKS 

may  be  used  for  the  same  purpose  (the  same  propor- 
tions), and  is  also  valuable  for  breaking  up  a  cold  in  the 
early  stages. 

Turpentine  is  sometimes  employed  in  the  proportion 
of  4  ounces  to  15  gallons  of  water,  as  an  old-fashioned 
alleviation  in  chronic  rheumatic  affections.  Care  must 
be  exercised  that  either  mustard  or  turpentine  is  thor- 
oughly mixed  with  the  water,  or  the  patient  may  easily  be 
burnt. 

Of  recent  years  baths  having  the  same  chemical  compo- 
sition as  the  well-known  mineral  waters  of  Nauheim,  Carls- 
bad, etc.,  and  given  in  conjunction  with  a  strict  regime  of 
diet,  exercise,  and  Swedish  movements,  have  become 
popular  in  treating  certain  forms  of  organic  heart  disease. 
The  system  is  known  as  the  Schott  system.  Bicarbonate 
of  soda,  8  ounces,  to  dilute  hydrochloric  acid  4  ounces, 
is  a  formula  frequently  prescribed,  but  usually  the  salts 
are  purchased  ready  prepared  under  the  name  of  the  special 
spring  required.  Such  baths  are,  however,  usually  given 
in  special  sanatoria. 

After  a  medicated  bath  the  patient  should  not  be  dried 
briskly,  the  object  being  that  the  skin  should  absorb  as 
much  of  the  medication  as  possible.  After  gentle  wiping 
to  remove  the  superficial  moisture  clean  garments  should 
be  put  on  and  the  patient  made  to  rest  quietly  in  bed  for 
an  hour.  In  the  Schott  system  the  patient  is  wrapped  in 
a  hot  clean  sheet  in  order  to  further  the  process  of  absorp- 
tion. 

Tub-bath  in  Bed. — In  cases  where  the  tub-bath  is  re- 
quired and  the  patient  unable  to  be  moved  from  the  bed, 
it  may  be  carried  out  in  the  following  manner  (Fig.  10) : 

A  rubber  sheet,  half  a  yard  longer  and  half  a  yard  wider 
than  the  mattress,  is  rolled  under  the  patient  (as  he  lies 
directly  on  the  rubber,  it  should  be  warmed  first).  Each 
corner  has  a  ring  sewed  to  it  by  which  it  can  be  tied  to  the 
bed-posts :  twelve  inches  from  each  corner  stout  tapes  are 
firmly  sewn  which,  when  tied  in  pairs,  bring  the  sides  of  the 
sheet  as  high  as  the  corners.  The  bath  is  further  given 
shape  by  rolled  blankets,  sand-bags,  or  pillows  placed  on 
each  side  of  the  bed  outside  the  rubber.  Pillows  are  also 


TUB-BATH    IN   BED  107 

arranged  for  the  patient's  head  under  the  rubber.  Two 
or  three  boards  placed  across  the  bed  under  the  hair 
mattress  prevent  too  much  sagging.  Under  cover  of  a 
light  blanket  the  night-dress  is  removed  and  the  loin 
towel  pinned  securely  in  place.  The  bath  is  then  quickly 
filled  from  pitchers  of  water  of  the  exact  temperature 
required. 

The  water  is  emptied  by  lowering  one  end  of  the  rubber 
over  a  bucket;  or  it  may  be  siphoned  off,  beginning  while 
the  bath  is  in  progress.  As  about  6  gallons  of  water  are 
required,  such  a  bath  is  a  lengthy  proceeding  unless  the 
patient's  bed  can  be  wheeled  into  a  bath-room,  where  the 


Fig.  10. — Tub-bath  in  bed.     Extemporized  from  rubber  sheet  and 

pillows. 

bath  can  be  filled  from  a  rubber  pipe  attached  to  the  tap, 
and  again  emptied  quickly  into  a  fixed  slop  sink.  A 
special  rubber  bath-tub  supplied  with  a  frame  by  which 
the  water  is  kept  in  a  fixed  position  is  also  sold  for  this 
purpose  under  .the  name  of  the  Burr  bed-bath,  but,  like 
all  rubber  goods,  is  expensive. 

The  bath  emptied,  the  rubber  is  untied  and  rolled  from 
beneath  the  patient,  who  is  dried  and  dressed  in  the  usual 
manner.  When  emptying,  the  head  of  the  bed  should  be 
raised  on  a  chair  or  couple  of  blocks,  to  prevent  the  water 
collecting  in  the  middle  of  the  bed. 

In  cases  that  have  had  slight  hemorrhages  a  Brandt 


108  BATHS   AND   PACKS 

bath  may  be  ordered  to  be  given  in  this  way.  The  move- 
ment necessary  is,  however,  greater  than  where  a  tub-bath 
is  given  skilfully  with  a  good  stretcher. 

In  many  cases  of  acute  illness  the  tub-bath  is  imprac- 
tical and  the  therapeutic  results  of  the  bath  must  be  at- 
tained by  other  methods.  The  results  chiefly  aimed  at, 
we  have  seen,  are  to  induce  perspiration,  to  relax  spasms, 
to  reduce  temperature,  and  to  allay  cerebral  symptoms. 
The  methods  most  frequently  employed  are  as  follows: 

The  Hot  Pack. — First:  Arrange  the  patient,  divested 
of  his  shirt,  between  two  hot  blankets  on  a  rubber  sheet, 
also  warmed. 

Second:  Wring  out  of  scalding  water  three  light,  small- 
sized  blankets  wrung  thoroughly  dry,  or  the  patient  may 
be  scalded.  (For  this  reason  heavy  blankets  are  not 
practical.)  Roll  the  blankets  in  a  warmed  rubber  sheet 
and  carry  quickly  to  the  patient's  bedside. 

Third:  Place  two  blankets  under  the  patient  (keeping 
him  closely  covered)  lengthwise  across  the  bed,  one  under 
the  shoulders,  one  from  the  waist  down;  bring  the  upper 
blanket  round  the  neck,  shoulders,  and  sides,  and  roll 
each  arm  up ;  bring  up  the  lower  in  the  same  way  and  roll 
up  each  leg  and  turn  the  lower  margin  up  over  the 
feet.  Place  the  other  blanket  over  the  patient,  slipping 
out  the  covering  blanket,  and  tuck  it  round  the  legs,  be- 
tween the  sides,  and  the  already  enveloped  arms,  and 
over  the  shoulders  very  thoroughly,  so  that  no  air  can 
penetrate. 

Fourth:  Bring  first  the  under  dry  blanket  and  then  the 
rubber  sheet  up  from  either  side  and  tuck  firmly  under  the 
opposite  side ;  turn  up  the  lower  margin  over  the  feet. 

Fifth:  Replace  the  covering  blanket,  tucking  it  firmly 
around  the  mummy-like  figure,  and  cover  with  the  ordinary 
bed-clothes. 

Sixth:  In  this  and  all  varieties  of  sweat-baths  cold, 
in  the  form  of  the  ice-cap  or  wet  compresses,  is  applied  to 
the  head,  and  unless  the  patient  is  unconscious,  he  is 
induced  to  drink  freely  during  the  bath.  Any  hot  or 
cold  drink  that  does  not  contain  food  requiring  digestion  is 
suitable,  such  as  water,  Vichy,  tea,  etc.  The  pulse  must 


THE    HOT    DRY    PACK  109 

be  frequently  taken  at  the  temple,  and  the  patient  closely 
watched  for  symptoms  of  exhaustion  or  faintness. 

In  cases  of  acute  illness,  where  immediate  action  of  the 
skin  is  imperative,  a  powerful  diuretic,  pilocarpin,  is  fre- 
quently ordered  to  be  given  at  the  same  time  as  the  sweat- 
bath.  Pilocarpin  is  the  active  principle  of  a  drug  called 
jaborandi.  Usually  it  is  given  hypodermically  (£  to  i 
grain  of  pilocarpin  hydrochlorid).  Five  to  ten  minutes 
after  pilocarpin  is  given  the  surface  becomes  violently 
flushed,  the  pulse  full  and  more  rapid,  and  the  patient 
breaks  out  into  profuse  perspiration,  beginning  with  the 
face  and  neck;  the  flow  of  saliva  is  also  greatly  increased. 
This  diaphoresis  may  continue  for  a  considerable  time. 
Pilocarpin  depresses  the  heart  and  nerve-centers  and  in 
rare  instances  has  been  known  to  cause  edema  of  the  lungs. 
Watch  must  be  kept  for  symptoms  of  heart  failure. 

The  sweat-bath  lasts  from  twenty  minutes  to  an  hour, 
according  to  conditions.  On  removal  the  patient  is  rolled 
without  exposure  between  hot,  dry  blankets;  when  sweating 
has  ceased,  he  is  rubbed  dry  with  hot  towels,  and,  if  desired, 
also  with  alcohol,  and  the  ordinary  clothes  replaced.  No 
patient  should  ever  be  left  alone  in  a  sweat-bath. 

From  the  practical  difficulty  of  insuring  that  the  blankets 
are  sufficiently  hot,  and  sufficiently  dry  not  to  scald  the 
patient,  other  methods  having  similar  results  are  preferred 
to  the  hot  pack.  It  should  be  remembered,  too,  that 
scalding  water  ruins  a  blanket. 

The  Hot  Dry  Pack. — Place  a  rubber  sheet  and  blanket, 
both  hot,  under  a  patient;  roll  him,  divested  of  his  shirt, 
in  the  hot  blanket;  place  hot-water  cans  or  bottles,  rubber 
hot-water  bags,  or  hot  bricks  wrapped  in  flannel  round  the 
patient;  cover  him  with  another  hot  blanket,  and  above 
that  a  second  rubber  sheet;  tuck  both  firmly  in  under  the 
mattress  and  round  the  neck ;  cover  with  as  many  blankets 
as  may  be  desired.  Apply,  as  usual,  cold  to  the  head,  and 
give  drinks  freely.  The  cans,  etc.,  must  be  carefully 
covered  and  arranged  outside  the  enveloping  blanket  in 
such  a  manner  that  the  patient  cannot  come  in  contact 
with  them  or  he  may  be  burnt. 

In  the  form  of  sweat-bath  most  in  use  the  patient  lies 


110  BATHS    AND    PACKS 

on  his  bed  in  what  is  practically  a  closed  cabinet,  his 
head  only  exposed;  the  air  in  the  cabinet  is  brought  to  a 
high  temperature  by  one  or  other  of  several  methods. 

To  arrange  such  a  cabinet  three  rubber  sheets,  three 
blankets,  and  a  couple  of  bed-cradles,  each  two  feet  long, 
are  required.  If  of  metal,  the  cradles  should  be  covered 
with  a  closely  wound  muslin  bandage  to  protect  the  clothes 
from  rust-marks.  The  rubber  sheets  and  blankets  should 
be  well  warmed. 

First:  Roll  one  blanket  and  rubber  sheet  under  the 
patient,  the  blanket  next  him,  and  cover  him  with  one  of 
his  bed  blankets;  remove  the  shirt. 

Second:  Place  the  cradles  so  that  they  extend  from  the 
shoulders  to  beyond  the  feet. 

Third:  Tie  a  bath  thermometer  to  the  cradle  so  that  it 
hangs  where  it  can  be  easily  reached. 

Fourth:  Bring  the  lower  blanket  round  the  shoulders 
and  neck  and  up  the  sides  and  ends  of  the  cradles  as  far 
as  they  will  reach. 

Fifth:  Cover  the  cradles  with  the  two  remaining  blankets 
placed  lengthwise  across,  and  arranging  them  so  that  they 
overlap  well.  Tuck  them  securely  all  round  between  the 
under  blanket  and  the  rubber  sheet.  Slip  out  the  blanket 
covering  the  patient  and  tuck  in  well  round  his  neck  and 
shoulders. 

Sixth:  Bring  up  the  rubber  sheet  in  the  same  manner. 

Seventh:  Cover  the  cradles  in  the  same  way  with  the 
two  remaining  rubber  sheets.  By  this  overlapping  all 
cold  air  is  excluded.  The  reason  for  placing  the  blankets 
before  the  rubber  is  that,  exposed  to  dry  heat,  rubber 
smells  disagreeably,  and  where  steam  heat  is  used,  the 
vapor  condenses  on  the  rubber  and  may  drip  on  the  patient. 
Any  number  of  blankets  desired  and  the  ordinary  bed- 
clothes may  be  added. 

The  cabinet  is  heated  by  hot  air,  vapor,  or  dry  heat  in 
the  following  way: 

The  Hot-air  Bath. — A  special  apparatus  is  sold  for 
this  purpose.  It  consists  of  a  large  alcohol  lamp  with  a 
metal  covering,  which  is  the  expanded  end  of  a  chimney  of 
convenient  shape  and  sufficiently  long  to  extend  just 


THE   HOT-AIR   BATH  111 

inside  the  cabinet  at  the  patient's  feet,  about  six  inches 
above  the  mattress.  The  lamp  is  placed  on  a  stool  of 
convenient  height  outside  the  bed.  The  coverings  are 
opened  to  admit  the  end  of  the  chimney  and  tucked 
closely  round.  For  this  reason  the  chimney  should  be 
covered  with  an  asbestos  wrapping,  or  the  bed-clothes 
may  be  burned.  Where  asbestos  cannot  be  had,  wet 
cloths  may  be  wrapped  round  the  chimney  and  kept 
damp. 

The  temperature  and  the  length  of  time  the  bath  is 
to  last  are  ordered  in  each  case.  Commonly,  fifteen  to 
thirty  minutes  after  the  required  temperature  is  reached 
is  ordered.  The  temperature  ordered  is  frequently  120° 
F.;  some  patients,  however,  can  stand  a  temperature  even 
higher.  The  temperature  in  all  cases  must  be  closely 
watched  and  regulated  by  the  thermometer  hanging  in 
the  cabinet.  It  must  be  placed  where  it  can  conveniently 
be  reached  through  a  lapping  of  the  coverings,  but  as 
far  as  practical  from  the  stream  of  hot  air. 

Where  moist  heat  is  desired,  a  croup  kettle  is  used,  the 
spout  being  directed  inside  the  covering  just  above  the 
feet.  The  croup  kettle  is  a  closely  covered  vessel  furnished 
with  a  long  spout,  from  which,  when  the  kettle  is  main- 
tained at  boiling-point,  a  steady  stream  of  steam  is  emitted. 
It  is  placed  over  a  lamp  at  a  convenient  height  outside  the 
bed;  the  temperature  ordered  is  generally  from  110°  to 
120°  F.,  the  duration  the  same  as  for  a  vapor-bath. 

Where  steam  heat  is  used,  a  square  of  blanket  should  be 
laid  over  the  feet  below  the  point  where  the  spout  enters. 
Droppings  from  the  spout  have  been  known  to  cause 
scalds.  Frequently  it  is  preferred  that  the  whole  body 
should  be  covered  with  a  single  light  blanket. 

In  places  where  electric  light  is  employed  the  desired 
temperature  can  quickly  and  very  simply  be  attained 
by  means  of  an  electric  drop  light  tied  to  one  of  the 
cradles  and  suspended  in  the  center  of  the  cabinet.  The 
candle  power  should  be  from  20  to  32.  The  method 
was  first  introduced  into  the  Polyclinic  Hospital,  Phila- 
delphia, by  Dr.  Samuel  Risley,  where  it  has  almost  wholly 
replaced  all  other  forms  of  sweat-bath,  and  is  now  being 


112 


BATHS    AND    PACKS 


adopted  by  several  other  hospitals.  It  is  simple,  quickly 
prepared,  and  given  with  less  danger  of  fire,  burns,  or 
scalds  than  the  methods  just  described.  Certain  pre- 
cautions, however,  must  be  borne  in  mind: 

First:  If  moisture  touches  the  globe,  it  will  burst  and 
the  patient  may  be  burnt. 

Second:  If  moisture  touches  the  cord,  the  insulation  is 
destroyed,  a  short  circuit  formed,  and  the  light  will  not 
burn. 

Third:  The  heat  given  out  by  an  electric  light  is  sufficient 
to  set  any  inflammable  substance  with  which  it  comes  in 
contact  on  fire. 


Fig.  11. — Cabinet  arranged  for  giving  sweat-bath  with  the  electric 
light  (Poly clinic  Hospital,  Philadelphia). 

For  these  reasons  a  detachable  collar  of  soft  lead  is,  at 
the  Polyclinic  Hospital,  wrapped  round  that  part  of  the 
apparatus  that  is  to  come  in  contact  with  the  coverings, 
and  a  like  precaution  should  always  be  taken. 

Sweat-baths  are  ordered  for  cases  of  nephritis,  acute  and 
chronic,  for  uremia,  in  some  specific  conditions,  and,  more 
rarely,  in  the  treatment  of  chronic  rheumatism  or  gout. 

The  records  of  such  treatment  should  be  kept  accurately 
on  the  charts,  and,  where  practical,  the  temperature,  pulse, 
and  respiration  should  be  taken  and  recorded  before  and 
immediately  after  each  bath.  Where  the  patient  has  to 


COLD   SPONGE  113 

be  forcibly  restrained,  as  in  the  violent  convulsions  of 
uremia,  the  pack  is  frequently  more  practical  than  the 
other  forms  of  sweat-bath.  If  the  patient  is  unconscious, 
it  is  important  to  observe  whether  urine  has  been  voided 
during  the  sweat-bath. 

Cold  Applications. — Where  the  tub-bath  is  either  not 
practical  or  not  desired,  cold  may  be  applied  to  the  entire 
body  by  other  methods.  The  following  methods  are 
chiefly  employed  to  reduce  temperature,  to  relieve  cere- 
bral conditions,  and  frequently  to  induce  sleep.  As  in 
the  case  of  the  cold  tub-bath,  the  process  may  prove  a 
severe  shock  to  the  patient,  and  he  should  be  closely 
watched  during  the  entire  time.  A  feeble,  intermittent 
pulse,  cyanosis,  and  shivering  are  again  the  symptoms 
that  the  bath  is  not  suiting  the  patient.  As  in  the  cold 
tub,  also,  the  pulse  should,  after  the  first  shock  of  cold, 
become  stronger  and  slower  and  the  cerebral  symptoms 
show  marked  improvement.  Frequently,  when  the  process 
is  over,  the  patient  falls  into  a  natural  sleep. 

In  all  cases  the  temperature,  pulse,  and  respiration  are 
taken  immediately  before  and  after  the  bath,  and  again 
in  half  an  hour  (unless  the  patient  is  asleep),  in  order  to 
observe  the  result. 

Cold  Sponge. — The  cold  sponge  is  ordered  chiefly  to 
reduce  temperature.  The  temperature  of  the  water  is 
usually  from  70°  to  60°  F.  or  lower,  and  the  sponging 
continued  for  from  twenty  minutes  to  half  an  hour  (Fig. 
12).  _ 

First:  Have  in  readiness  a  deep  basin  half  full  of  water 
at  the  required  temperature,  a  bath  thermometer,  a  basin 
of  chopped  ice,  a  large  wash-cloth,  an  ice-cap,  and  a  hot- 
water  bag. 

Second:  Remove  the  top  bed-clothes  and  shirt,  covering 
the  patient  with  a  light  single  blanket  or  sheet.  Roll 
under  him,  above  the  usual  bed-clothes,  a  rubber  sheet 
large  enough  to  cover  the  bed.  If  desired,  a  sheet  may 
be  placed  between  the  rubber  and  the  patient,  but  is  not 
necessary. 

Third:  Place  the  ice-cap  on  the  head  and  the  hot-water 
bag  at  the  feet. 
8 


114 


BATHS  AND   PACKS 


Fourth:  Sponge  with  a  wet  sponge  in  long,  single  strokes, 
exposing  each  limb  in  turn  and  the  entire  chest,  dividing 
the  time  equally  between  each.  For  the  last  five  minutes 
turn  the  patient  and  sponge  the  back  in  the  same  manner. 
Regulate  the  temperature  of  the  water  by  adding  ice. 

Fifth:  Dry  by  gentle  wiping,  roll  out  the  rubber  sheet, 
and  replace  the  shirt  and  covering;  or,  if  desired,  the 
patient  may  be  wrapped  in  a  dry  sheet  for  half  an  hour 
before  this  is  done,  and  the  shirt  replaced  when  the  tem- 
perature is  taken.  The  results  on  the  temperature  appear 


Fig.  12. — Cold  sponge  to  reduce  temperature. 

the  same  in  either  case.     The  covering  should  consist  of  a 
single  sheet. 

Where  a  closer  imitation  of  a  Brandt  bath  is  desired, 
the  sponge  is  somewhat  modified.  The  body  is  fully 
exposed  except  for  the  loin  cloth;  as  much  water  as  possible 
(temperature,  50°  to  40°  F.)  is  then  taken  up  in  the  sponge, 
which  is  squeezed  over  the  limbs,  chest,  and  back  in  turn 
by  one  hand,  while  the  other  gives  brisk  friction  to  the 
part.  The  sponging  over,  the  patient  is  briskly  dried  with 
rough  towels.  The  effect  desired  is  the  same  as  when  the 
Brandt  bath  is  used.  Unless  two  nurses  can  give  the  bath 


THE   COLD   AFFUSION 


115 


at  the  same  time,  the  process  is  often  found  too  long  and 
chilling. 

The  Cold  Affusion  (Fig.  IS).— First:  Place  two  long 
rubber  sheets,  well  overlapping,  under  the  patient,  so  that 
the  bed  is  entirely  covered;  the  lower  rubber  must  be  of 
sufficient  length  that  one  end  can  be  gathered  into  a  foot- 
bath placed  on  the  floor. 

Second:  Place  pillows,  rolled  blankets,  or  sand-bags  on 
either  side,  the  patient  under  the  rubber  sheet  and  a 
pillow  under  his  head,  so  that  a  trough  of  rubber  is  formed. 


Fig.  13. — Cold  affusion  to  reduce  temperature. 

Third:  Place  an  ice-bag  on  his  head. 

Fourth:  Pin,  under  cover,  a  loin  towel  round  the  patient 
and  remove  all  the  coverings. 

Fifth:  Raise  the  head  of  the  bed  on  blocks  about  12 
inches. 

Sixth:  Attach  a  rubber  hose  to  a  tap  of  cold  water  and 
direct  the  stream  over  the  patient,  beginning  at  the  chest; 
before  ending,  the  patient  is  turned  on  his  face  and  the 
same  treatment  given.  Arranged  in  this  manner,  the 
water  will  run  off  the  patient  into  the  foot-tub.  The 


116  BATHS   AND    PACKS 

stream  should  be  begun  gently.  From  three  to  five  minutes 
is  usually  prescribed.  Where  no  tap  is  conveniently  near, 
a  garden  watering-can  may  be  substituted,  or  water  may  be 
siphoned  over  the  patient  by  a  bath  hose  from  a  bucket 
or  tank  placed  a  couple  of  feet  above  the  patient's  head. 

The  cold  affusion  is  not  much  employed  in  the  course 
of  a  long  illness  associated  with  high  temperature.  It  is 
of  great  value  in  treating  sudden  accesses  of  hyperpyrexia, 
as  in  thermic  fever,  where  the  temperature  may  rise  to 
110°  F.  and  over.  In  this  condition  the  affusion  may  be 
kept  up  a  much  longer  time,  the  pulse  being  closely  watched. 

The  Ice-rub. — The  patient,  exposed  except  for  the 
loin  towel,  is  placed  on  a  rubber  sheet  and  the  limbs,  chest, 
and  back  in  turn  rubbed  for  from  three  to  five  minutes 
with  flat  pieces  of  ice  wrapped  in  gauze.  An  ice-bag 
should  be  kept  on  the  head  and  a  hot-water  bag  at  the  feet. 
This  process  is  sometimes  preferred  to  the  cold  sponge. 

Ice-cradles. — A  process  known  as  cradling  is  sometimes 
effective  in  keeping  a  temperature  for  hours  at  a  time 
two  or  more  degrees  below  that  otherwise  maintained. 
Large  bed-cradles  are  placed  over  the  body  and  covered 
with  a  single  sheet  turned  back  somewhat  at  the  feet  and 
neck.  The  night-shirt  is  rolled  up  under  the  arms. 
From  the  cradles  are  suspended  several  small,  uncovered 
buckets  filled  with  lumps  of  ice.  The  buckets  must 
be  well  made  or  they  will  leak  unpleasantly,  and  the  ice 
will  require  constant  renewal.  If  the  patient  complains 
of  shivering  and  discomfort,  a  hot-water  bag  may  be  placed 
at  the  feet.  An  ice-cap  is  usually  applied  to  the  head. 

Ice  Paddling. — Where  better  means  are  not  procurable, 
a  temperature  may  be  reduced  by  inducing  the  patient  to 
paddle  his  hands  in  cold  or  iced  water.  A  basin  half  full 
of  water  the  required  temperature  is  placed  on  the  bed 
under  each  hand,  and  the  patient  directed  to  "  paddle  " 
the  water  about.  The  water  should  be  sufficiently  deep 
that  the  wrist  may  be  covered.  This  simple  method  often 
has  surprising  results  where  the  patient  is  not  too  sick 
to  make  the  necessary  exertion.  In  district  nursing  it 
is  a  method  that  can,  with  less  risk  than  any  other,  be 
carried  out  in  the  nurse's  absence. 


COLD    PACK 


117 


Cold  Pack. — The  cold  pack  consists  in  wrapping  a  patient 
in  a  cold  wet  sheet,  with  the  object  either  of  reducing 
temperature  or  relieving  nervous  conditions:  frequently 
both  results  are  desired  at  the  same  time  (Fig.  14). 

First:  Wring  two  sheets  in  cold  tap-water  and  bring 
them  in  a  basin  to  the  patient's  bedside,  together  with  an 
ice-cap,  a  cold  drink  (Vichy,  water,  etc.),  and  three  single 
blankets. 

Second:  Roll  the  three  single  blankets  under  the  patient, 
remove  the  shirt,  covering  him  with  a  single  sheet. 


Fig.  14. — Giving  a  wet  pack. 

Third:  Roll  one  wet  sheet  under  him,  bring  it  up  over 
his  feet,  shoulders,  and  sides,  and  fold  it  over  the  limbs: 
cover  with  the  second  wet  sheet,  removing  the  dry  sheet 
at  the  same  time.  Tuck  well  in  round  the  neck,  under  the 
axilla  and  sides,  and  between  the  legs.  Every  inch  of  the 
body  should  thus  be  in  contact  with  the  wet  sheet. 

Fourth:  Bring  the  right  side  of  one  blanket  across  the 
body  and  tuck  it  very  firmly  in  on  the  left  side;  bring 
the  left  side  up  and  tuck  it  also  very  firmly  in  on  the  right; 
turn  the  end  over  the  feet:  in  this  way  not  an  inch  of  the 
sheet  should  be  uncovered,  the  object  being  to  exclude 


118  BATHS   AND    PACKS 

all  air.  Do  exactly  the  same  with  each  remaining  blanket 
in  turn. 

Fifth:  Cover  with  sheet  or  bed-spread;  place  the  ice- 
cap on  the  head  and  give  the  patient  the  drink.  Take 
the  pulse  at  the  temple  and  watch  it  closely.  As  a  rule, 
the  pack  is  well  borne. 

The  patient  may  be  left  in  the  pack  for  an  hour,  or  for 
longer  if,  as  frequently  happens,  he  falls  asleep.  After 
the  first  shock  the  sensation  induced  is  pleasant  and  very 
soothing.  While  such  a  pack  has  sometimes  but  little 
immediate  effect  on  the  temperature,  the  cerebral  symp- 
toms, even  violent  delirium,  are  usually  greatly  reduced, 
and  the  rest  thus  procured  eventually  exerts  a  good  influ- 
ence on  the  temperature  also.  The  temperature,  pulse, 
and  respiration  are,  as  usual,  taken  immediately  before 
and  after  the  pack,  and  again  after  half  an  hour's  in- 
terval. In  some  nervous  conditions,  not  associated  with 
pyrexia,  a  cold  pack  is  ordered  at  bedtime  to  induce  sleep, 
often  with  excellent  results.  It  may  also  be  ordered  in  the 
treatment  of  chorea. 

When  the  pack  is  over,  the  patient  is  lightly  dried, 
rubbed  briskly  with  alcohol,  and  the  usual  clothes  replaced. 

Where  the  first  object  is  the  immediate  reduction  of  a 
high  temperature,  the  pack  is  given  by  a  somewhat 
different  method: 

First:  Place  the  patient,  covered  with  a  single  sheet,  on 
a  large  rubber  sheet  and  remove  the  shirt. 

Second:  Bring  in  a  basin  two  sheets  wrung  out  of  cold 
tap-water,  place  one  below  and  one  over  him,  tucking 
the  sheets  in  between  the  legs,  arms,  and  sides. 

Third:  Have  a  third  sheet  in  a  foot-bath  full  of  iced 
water.  Every  three  minutes  change  one  or  other  sheet. 
The  upper  sheet  is  usually  changed  twice  as  frequently  as 
the  lower.  Instead  of  the  upper  sheet  large  towels  may  be 
used,  one  for  each  limb  and  one  for  the  body,  and  are 
changed  in  turn.  Lumps  of  ice  wrapped  in  gauze  or  old 
muslin  may  be  placed  in  the  axilla  and  round  the  sides, 
and  the  ice-bag  is  applied  to  the  head.  The  pack  is  com- 
monly ordered  for  from  fifteen  to  twenty  minutes.  After 
it  is  finished  the  patient  is  dried,  rubbed  with  alcohol,  and 
the  ordinary  clothes  again  replaced. 


CHAPTER  III 
LOCAL  APPLICATIONS 

Inflammation — Heat  and  Cold:  Cold  Compress,  Stupe,  Ice-bag, 
Ice-coils — Ice  Poultice — Heat — Hot-water  Bag — Bran—Salt — Cot- 
ton Jacket  —  Poultices  — •  Stupes — Compresses — Counterirritants — 
Rubefacients  — Sinapism — Cupping — Leeches — lodin— Ironing — Ac- 
tual Cautery — Vesicants  — •  Blistering  Fluid  —  Ointment  —  Flying 
Bl  ister — Pustulants — Escharotics — Liniments — Plasters — Antiphlo- 
gistine. 

IN  the  following  chapter  it  is  suggested  that  a  lesson  be 
preceded,  or  directly  followed,  by  a  demonstration  in 
which  all  the  varieties  of  applications  mentioned  should  be 
viewed  and  handled  by  the  class,  and,  where  necessary, 
prepared.  During '  the  succeeding  weeks  the  lessons 
should  be  constantly  practised  in  the  wards,  accurate 
methods  closely  insisted  on,  and  the  effects  of  the  applica- 
tions employed  pointed  out. 

Local  applications  to  the  skin's  surface  are  constantly 
employed  to  relieve  pain  and  allay  inflammation,  to  pro- 
mote absorption  of  fluids,  to  overcome  certain  spasmodic 
or  nervous  conditions,  and  to  stimulate  the  activity  of  an 
organ.  It  seems  practical  here  to  give  a  brief  sketch 
of  the  cause  and  process  of  inflammation,  for  the  relief  of 
which  the  larger  number  of  the  applications  to  be  described 
are  employed. 

INFLAMMATION 

Inflammation  is  the  local  result  of  some  local  lesion, 
which  may  be  due  to  an  injury  to  the  tissues,  as  in  a  sprain, 
a  fracture,  or  a  burn,  or  to  bacterial  invasion,  as  in  pneu- 
monia, a  boil,  etc.  Inflammation  is  always  described  as 
possessing  five  classic  symptoms:  redness,  heat,  swelling, 
pain,  and  interference  with  function.  In  order  to  under- 
stand the  effect  of  local  applications  on  inflammation 
and  their  proper  use  we  must  understand  to  some  extent 
the  cause  and  process  of  inflammation. 

119 


120  LOCAL   APPLICATIONS 

The  first  demand  of  an  injured  part  is  to  have  a  larger 
supply  of  blood  to  repair  the  ravage.  By  the  action  of  the 
vasomotor  nerves  the  blood-vessels  of  the  affected  area 
become  dilated,  and  the  rush  of  blood  to  the  part  produces 
the  first  two  symptoms  enumerated  above — redness  and 
local  heat.  Swelling  quickly  follows  as  the  result  of  the 
blocking  of  the  vessels  with  the  oversupply  of  blood. 
More  is  accumulated  than  can  quickly  be  carried  off  by 
the  arterioles  and  capillaries;  pressure  results,  and  the 
fluid  portion  of  the  blood  is  squeezed  out  of  the  vessels 
into  the  interstices  of  the  tissues.  At  the  same  time 
certain  of  the  white  corpuscles,  by  their  independent 
movements,  migrate  from  the  blood-vessels  and  accumulate 
in  large  numbers  at  the  seat  of  lesion.  The  smaller  blood- 
vessels are  blocked  with  closely  packed  red  corpuscles. 

It  will  be  remembered  that  the  property  of  many  of  the 
white  corpuscles  is  to  act  as  the  scavengers  of  the  body; 
they  perform  this  act  by  fastening  on  any  foreign  body, 
such  as  bacteria,  inflammatory  processes,  etc.,  and  either 
destroying  them  by  ingestion  or  carrying  them  to  other 
parts  of  the  body.  The  white  corpuscles  that  possess 
this  property  are  called  phagocytes. 

The  accumulation  of  fluid  and  corpuscles  in  the  tissues 
causes  swelling,  and  consequently  pain,  from  the  pressure 
of  the  swollen  parts  on  the  nerve  terminations.  Pain  not 
the  result  of  inflammation  may  be  present  from  the  be- 
ginning as  the  result  of  direct  injury  to  the  nerves  them- 
selves, as  in  a  burn,  a  fracture,  etc. 

From  these  conditions  interference  with  function  results 
and  is  usually  easily  demonstrated :  a  swollen  hand  cannot 
be  used  or  a  swollen  eyelid  opened.  These  examples 
demonstrate  only  loss  of  motor  power.  Interference 
with  the  functions  of  the  vital  organs  of  the  body  is 
a  more  serious  condition.  Inflammation  of  the  lungs  cuts 
off  the  supply  of  oxygen  from  the  body.  In  the  kidneys 
it  diminishes  the  secretion  of  urine  and  checks  the  excretion 
of  urea.  Inflammation  of  any  part  of  the  heart  deranges 
the  entire  circulation,  and  so  on,  throughout  the  whole 
anatomy. 

Under  benign  conditions  inflammation  terminates  in 


INFLAMMATION  121 

what  is  known  as  resolution.  The  inflammatory  processes 
and  exudations  are  carried  off  by  the  lymphatic  circula- 
tion, and  are  partly  eliminated  from  the  system  by  the 
excreta,  and  partly  absorbed;  the  swelling  subsides,  and 
the  circulation  resumes  its  normal  course. 

Frequently,  however,  resolution  is  not  attainable. 
The  injury  may  be  so  severe  that  the  wounded  tissue  can- 
not be  revitalized,  and  forms  a  foreign  body  too  extensive  to 
be  absorbed  by  the  white  corpuscles;  or  the  affected  area 
may  become  invaded  with  bacteria.  A  greater  number  of 
white  corpuscles  migrate  to  the  seat  of  lesion,  many  of 
which  die,  and,  together  with  the  injured  tissues,  break 
down  or  disintegrate  into  a  thick,  greenish-yellow  fluid 
that  we  know  as  pus.  The  process  by  which  pus  is  formed 
is  called  suppuration,  and  a  local,  circumscribed  collec- 
tion of  pus  is  known  as  an  abscess. 

The  cardinal  treatment  of  inflammation  consists  of 
absolute  rest  of  the  affected  part  and  the  local  application 
of  cold,  heat,  or  a  counterirritant;  continuous  pressure 
is  also  sometimes  used,  especially  in  connection  with  cold 
applications. 

An  intelligent  understanding  of  the  application  of  cold 
and  heat  will  enable  one  to  determine  which  to  apply  to 
the  individual  case.  Both  act  to  some  extent  as  a  local 
anesthetic  to  the  irritated  nerve  terminations,  thus  re- 
lieving pain.  Heat,  however,  penetrates  further  than  cold, 
and  moist  heat  further  than  dry.  Cold  acts  by  causing 
contraction  of  the  peripheral  blood-vessels,  thus  reducing 
the  blood-supply,  and  by  this  means  lessening  the  conges- 
tion. Heat  dilates  the  blood-vessels  and  reduces  inflam- 
mation by  enlarging  their  capacity  for  an  increased  blood- 
supply.  It  also  causes  a  still  greater  increase  of  blood  to 
the  parts,  with  a  larger  outpouring  of  white  corpuscles, 
a  condition  which,  as  a  consequence,  also  promotes  suppu- 
ration when  continued  long.  Heat  has  further  the  valu- 
able effect  of  relaxing  muscular  spasm  or  rigidity. 

In  superficial  inflammations,  where  the  skin  is  not 
denuded,  cold  is  preferred.  Where  the  injury  has  not 
involved  large  areas  of  tissues,  and  sudden  acute  pain 
bears  evidence  of  wrenched  or  torn  nerves,  a  profuse 


122  LOCAL   APPLICATIONS 

blood-supply  is  not  necessary  to  repair  the  damage,  and  the 
less  exudation  there  is  to  absorb,  the  quicker  will  the 
normal  condition  be  reestablished.  A  sprain  is  a  typical 
example  of  such  an  injury. 

When  larger  areas  of  tissues  are  injured,  as  in  extensive 
bruises  or  contused  wounds,  the  nutrition  of  the  tissues  is 
impaired,  and,  if  the  blood-supply  is  lessened  or  cut  off, 
death  of  the  parts  will  take  place  and  the  tissues  slough. 
Heat  applied  will  minimize  the  danger  by  bringing  to  the 
seat  of  lesion  a  large  supply  of  blood,  which  will  not  only 
help  to  revitalize  the  tissues,  but,  where  local  death  has 
already  occurred,  will,  by  promoting  suppuration,  hasten 
the  separation  of  the  slough  from  the  living  tissues. 

In  deep-seated  inflammation  cold  is  usually  ordered 
where  the  consequence  of  an  overstimulated  circulation  are 
dangerous  or  distressing,  as  in  conditions  of  cerebral  in- 
flammation and  some  heart  affections;  and  heat,  where 
pain  is  a  prominent  symptom,  as  in  pleurisy  or  perito- 
nitis, in  which  latter  instance  heat  also  helps  to  relax 
muscular  rigidity.  In  some  circumstances  heat  and  cold 
may  be  used  together:  for  example,  in  cerebral  conditions, 
such  as  threatened  apoplexy,  cold  may  be  applied  to  the 
head  to  reduce  the  local  blood-supply,  while  heat,  applied 
at  the  same  time  to  the  abdomen  or  to  the  lower  extrem- 
ities will,  by  dilating  the  blood-vessels  in  a  remote  region, 
still  further  restrict  the  circulation  of  blood  in  the  head. 
Generally,  heat  and  cold,  when  used  as  local  applications, 
are  applied  directly  over  the  affected  area,  generously 
overlapping  it. 

The  action  of  the  third  form  of  local  irritation,  the  coun- 
terirritant,  is  more  prompt  than  either  heat  or  cold.  A 
counterirritant  is  an  application  which  irritates  the  per- 
ipheral nerves,  stimulates  the  circulation  by  dilatation  of 
the  superficial  blood-vessels,  and  causes,  by  reflex  action, 
changes  in  adjacent  or  in  more  distant  tissues.  The 
effects  of  a  counterirritant  are  various : 

First:  Through  the  stimulation  of  the  circulation  the 
processes  of  absorption  and  secretion  are  hastened. 

Second:  The  dilatation  of  the  superficial  blood-vessels 
relieves  congestion  and  the  pain  due  to  pressure,  and  causes, 


APPLICATION   OF   COLD  123 

by  reflex  action,  contraction  of  the  blood-vessels  in  more 
remote  regions. 

Third:  By  the  dilatation  of  the  lymphatic  vessels 
effusions  and  inflammatory  products  are  more  quickly 
removed  from  the  seat  of  lesion. 

Fourth:  Irritation  of  the  peripheral  nerves  produces  a 
reflex  action  by  which  the  sensitiveness  of  overirritated 
nerves  in  other  parts  is  reduced. 

A  counterirritant  may  be  applied  directly  over  the 
affected  area,  or  to  a  part  more  or  less  remote,  with  which 
it  has  some  nervous  communication,  either  direct  or  in- 
direct. For  example  of  the  latter:  acute  frontal  headache 
may  be  relieved  by  a  counterirritant  applied  at  the  back 
of  the  neck,  or  cerebral  congestion  by  a  mustard  poultice 
applied  to  the  abdomen. 

Applied  over  the  heart,  a  counterirritant  acts  as  a 
stimulant  to  that  organ  in  conditions  of  syncope  or  col- 
lapse. Applied  over  the  epigastrium,  it  is  efficacious  in 
checking  nervous  vomiting.  In  this  condition  the  effect 
is  produced  in  two  ways :  By  stimulation  of  the  circulation 
in  the  stomach  it  increases  the  natural  secretions  of  the 
organ,  and,  secondly,  it  has  a  soothing  effect,  through 
reflex  action,  on  the  overirritated  nerve-centers  which 
control  the  act  of  vomiting. 

APPLICATION   OF   COLD 

MOIST  COLD 

Cold  is  applied  wet  in  the  form  of  compresses  and  stupes. 

Ice  Compress. — For  ice  compresses  a  bowl  with  a 
large  lump  of  ice  and  a  small  quantity  of  sterile  water  is 
required,  and  several  pieces  of  lint,  gauze,  or  old,  clean 
muslin,  cut  the  required  size.  If  gauze  is  used,  about 
six  thicknesses  are  required  and  the  gauze  should  be  folded 
so  that  no  unraveled  edges  are  left.  The  compresses  are 
kept  in  the  iced  water.  In  applying  they  are  squeezed 
nearly  dry,  and  changed  before  they  have  time  to  become 
warm. 

In  the  large  majority  of  cases  ice  compresses  are  used 
for  eye  affections  and  applied  constantly  over  the  closed 


124  LOCAL  APPLICATIONS 

eyelid  for  many  hours  at  a  time.  The  compress  should 
be  cut  slightly  larger  than  the  eye.  Should  both  eyes  be 
affected,  the  same  compress  must  not  be  used  for  both 
eyes.  In  infectious  cases  each  compress  must  be  used  only 
once  and  discarded;  the  hand,  also,  should  be  protected 
by  a  rubber  glove  and  frequently  rinsed  in  a  disinfectant 
solution:  boric  acid  (a  2  per  cent,  solution)  may  be  or- 
dered in  place  of  sterile  water.  In  operative  cases  or 
cases  in  which  there  is  any  wound  strict  aseptic  methods 
must  be  observed. 

Constant  ice  compresses  are  frequently  ordered  in  the 
early  stages  of  ophthalmia  of  the  new-born.  The  treat- 
ment may  be  carried  out  efficiently,  and  without  over- 
fatigue,  in  the  following  manner: 

The  baby  is  wrapped  in  a  light  blanket  so  as  to  pinion 
the  arms,  and  placed  on  a  pillow  on  a  table.  The  nurse 
sits  at  the  table  directly  behind  the  infant's  head.  A 
piece  of  rubber  sheeting  is  placed  under  the  head  and  over 
the  shoulders,  to  avoid  dampening  the  clothes,  and  the 
light  is  carefully  shaded.  A  basin  containing  the  com- 
presses and  one  for  the  soiled  pledgets  are  at  hand  on  the 
table.  In  this  position  a  nurse  may  work  for  hours 
comfortably  for  both  herself  and  the  child. 

Compresses  of  a  larger  size,  applied  in  the  same  way,  may 
be  ordered  for  the  relief  of  frontal  headache  and  for  other 
local  inflammations.  Iced  water  may  be  used  alone  or 
diluted  with  vinegar,  alcohol,  or  a  toilet  water  that  is  not 
too  heavily  scented,  either  of  which  forms  an  evaporating 
lotion. 

In  the  treatment  of  sprains  and  injuries  of  like  nature, 
the  compress  is  frequently  applied  with  a  firm  bandage, 
which,  by  constant  pressure,  assists  in  preventing  the  swell- 
ing due  to  exudation.  The  limb  should  be  raised,  and, 
where  practicable,  the  affected  part  should  be  uncovered, 
except  for  the  dressings.  The  compress  can  be  kept  wet 
by  sopping  the  bandage  frequently.  Vinegar,  alcohol, 
a  solution  of  subacetate  of  lead,  or  alcohol  and  subacetate 
of  lead  combined,  may  be  used  with  the  iced  water,  an 
evaporating  lotion  causing  more  intense  cold  than  water 
alone. 


APPLICATION    OF    COLD  125 

Opium  is  also  used  with  lead  where  the  pain  is  severe 
(lead  and  laudanum  lotion),  and  chlorid  of  lime,  one  ounce 
to  one  quart,  is  useful  for  its  astringent  properties.  Where 
the  surface  has  become  broken,  however,  sterile  water  or 
a  mild  antiseptic  lotion  only  can  be  used. 

Ice  Stupe. — An  ice  stupe  is  a  covered  compress  and  may 
be  made  of  gauze,  cotton,  or  old  muslin.  It  is  squeezed 
until  just  dry  enough  not  to  drip,  and  covered  with  a  piece 
of  thin  rubber  sheeting,  oiled  silk,  rubber  tissue,  or  wax 
paper;  any  material,  in  fact,  that  will  keep  in  the  moisture. 
The  cover  should  overlap  the  stupe  one  inch  in  all  direc- 
tions. It  may  be  kept  in  position  by  a  bandage,  and 
should  be  changed  before  it  feels  warm.  The  ice  stupe  is 
frequently  ordered  as  a  throat  application;  applied  closely 
round  the  neck  it  gives  great  relief  in  painful  forms  of 

tonsillitis,  etc. 

DRY  COLD 

The  most  common  methods  of  applying  dry  cold  to  the 
surface  locally  are  by  the  ice-bag  or  the  ice-coil.  An  ice 
poultice  is  also  used,  but  more  rarely. 

Ice-bag. — An  ice-bag  is  made  of  rubber  or  of  waterproof 
material,  and  may  be  had  in  various  sizes,  suitable  for  ap- 
plication to  the  head,  the  spine,  the  abdomen,  the  throat, 
or  the  ear.  The  round,  medium-sized  ice-bag  or  cap  may, 
however,  be  adjusted  to  most  uses.  When  an  ice-bag  is 
not  procurable,  one  may  be  improvised  from  the  bladder 
of  a  sheep,  taking  care  to  tie  the  opening  securely.  In 
filling  an  ice-bag  it  should  be  remembered  that  the  less 
the  amount  of  air  admitted  into  the  bag,  the  longer  the  ice 
will  last.  When  filled,  the  bag  should  be  gathered  closely 
in  one  hand  to  press  out  the  air  while  the  top  is  adjusted. 
For  the  same  reason  water  should  be  emptied  out  of  the 
bag  as  soon  as  it  forms.  Small  lumps  of  ice  without 
sharp  edges  are  used  to  fill  the  bag  unless  the  patient 
has  to  rest  or  lie  upon  it,  when  crushed  ice  only  must 
be  used  and  the  bag  not  more  than  half  filled;  in  this 
circumstance  it  will  require  to  be  very  frequently  re- 
plenished. In  many  instances  the  weight  of  the  ice- 
bag  cannot  be  borne  and  should  then  be  suspended  so 
that  it  just  touches  the  surface  of  the  affected  part.  An 


126  LOCAL   APPLICATIONS 

ice-bag  for  a  limb  or  the  abdomen  may  be  hung  from 
a  bed-cradle,  or  for  the  head  from  the  railing  of  the  bed- 
stead. When  it  is  desired  to  keep  the  ice-bag  closely  on 
one  spot  (as  over  a  special  area  of  the  lung  in  pneumonia), 
it  may  be  kept  in  place  by  two  turns  of  a  bandage  round 
the  body,  and  can  be  removed  for  filling  without  undoing 
the  bandage.  An  ice-bag  should  be  used  with  a  slip-cover 
of  muslin  or  Canton  flannel,  or,  failing  these,  should  be 
wrapped  in  a  clean  towel.  Except  when  applied  over  the 
hair,  a  fold  of  lint  or  flannel  should  be  placed  between  the 
bag  and  the  bare  skin,  to  prevent  the  risk  of  freezing  small 
portions  of  the  surface. 

An  ice-bag  applied  to  the  head  is  a  common  means  of 
relieving  cerebral  congestion  or  of  reducing  the  general 
temperature  of  the  body.  Placed  over  the  epigastrium, 
it  may  allay  persistent  vomiting,  and  over  the  abdomen 
may  also  be  used  to  reduce  temperature.  It  is  a  valuable 
application  to  all  forms  of  local  inflammation  where  cold 
treatment  is  indicated. 

After  use  the  ice-bag  must  be  carefully  dried  and  packed, 
until  again  required,  with  sufficient  cotton  or  gauze  to 
keep  the  surfaces  apart. 

Ice-coils. — An  ice-coil  consists  of  a  coil  of  rubber 
tubing  (Fig.  15)  through  which  iced  water  can  be  kept 
continually  flowing.  It  can  be  laid  over  an  affected  area, 
and  from  its  lightness  is  usually  an  acceptable  applica- 
tion to  the  patient.  It  is  most  frequently  used  over  the 
abdomen,  either  for  local  application  or  to  reduce  the  gen- 
eral bodily  temperature,  but  it  may  be  applied  to  any  part 
free  from  pressure.  Obviously,  the  water  will  not  flow 
if  the  tubes  are  compressed  from  the  patient  lying  on  any 
part  of  them. 

A  special  coil  is  sold  under  the  name  of  Letter's  coils. 
Fine  rubber  tubing  is  used,  coiled  round  and  round  from 
the  center,  and  kept  in  place  by  double  pieces  of  webbing 
radiating  from  the  center  and  sewn  together  between  each 
coil.  It  has  the  appearance  of  a  large  solid  spider's  web. 
The  center  portion  only  of  the  tubing  is  coiled,  a  free 
length  at  either  end  communicating,  the  one  with  a  tank 
or  bucket  containing  water  and  ice,  placed  a  couple  of 


APPLICATION   OF    COLD 


127 


feet  higher  than  the  patient,  the  other  with  a  bucket  on  the 
floor.  A  funnel  covered  with  gauze  to  prevent  impurities 
from  the  ice  from  entering  the  tube  is  attached  to  the 
upper  length  of  tubing  and  inverted  in  the  tank  of  water. 
The  upper  tube  should  also  be  fitted  with  a  U-shaped 
connecting  tube  of  glass  or  hard  rubber,  placed  over  the 
edge  of  the  tank,  as  the  soft  tubing  will  become  compressed 
against  the  sharp  edge.  By  loosely  knotting  the  tubing  the 
flow  may  be  regulated.  It  is  sufficient  if  the  water  just 
trickles  through.  The  temperature  of  the  water  is  regu- 
lated by  lumps  of  ice.  To  start  the  water  flowing  it  is 


Fig.  15. — Application  of  the  cold-water  coil  to  the  chest  in  croupous 
pneumonia  or  pleurisy.     Leiter  coil. 

generally  necessary  to  run  water  through  the  coil  from  a 
pitcher;  when  running  freely,  the  lower  end  of  the  tubing 
is  pinched  and  the  funnel  placed  in  the  tank.  Once  started, 
the  flow  will  continue,  unless  the  tube  becomes  blocked. 
When  the  upper  bucket  is  nearly  empty,  the  buckets  can 
change  places,  and  the  same  water,  with  the  addition  of 
fresh  ice,  be  used  again. 

Small  coils,  for  application  to  the  ear,  etc.,  or  for  chil- 
dren can  be  easily  contrived.  Fine  rubber  tubing  should 
be  used  and  should  be  coiled  in  the  manner  described  on 
a  piece  of  firm  muslin.  Each  coil  can  be  kept  in  place  by 
a  few  loose  stitches  over  the  tubing.  While  making  the 


128  LOCAL    APPLICATIONS 

coil,  the  "  web  "  should  be  laid  flat  on  a  table  in  order  to 
avoid  twisting  the  rubber.  A  piece  of  lint  or  flannel 
should  also  be  placed  between  the  coils  and  the  surface  of 
the  skin  in  applying. 

Ice  Poultice. — An  ice  poultice  consists  of  small  pieces 
of  ice  freely  mixed  with  flaxseed  meal  or  with  bran.  Salt 
is  frequently  added,  and  gives  a  more  intense  cold.  The 
mixture  is  spread  between  two  pieces  of  gutta-percha  tis- 
sue, the  lower  of  which  is  cut  two  inches  larger  than  the 
upper.  The  edges  of  the  lower  are  folded  over  the 
upper,  and  the  two  pieces  sealed  together  with  chloroform 
or  turpentine,  or  by  passing  quickly  over  the  edges  a 
lighted  match. 

The  ice  poultice  is  not  so  frequently  used  as  other 
cold  applications,  but  it  may  be  a  valuable  substitute  when 
little  ice  can  be  had,  and  is  sometimes  preferred  as  an 
application  for  bruises  about  the  face  and  eyes,  or  in  ear 
affections,  especially  among  country  practitioners. 

HOT  APPLICATIONS 

DRY  HEAT 

The  Hot-water  Bag. — Familiar  as  are  its  uses,  simple  as 
it  is  to  handle  intelligently,  probably  more  than  one-half 
the  accidents  -in  nursing  are  caused  by  careless  use  of  the 
hot-water  bag.  Patients  are  either  scalded  by  the  bag 
bursting,  or  burnt  by  prolonged  contact  with  the  bag  while 
in  an  unconscious  or  helpless  condition.  More  than  one 
hospital  has  been  heavily  fined  and  subjected  to  expensive 
litigation  by  just  such  an  accident,  an  accident  that  the 
simplest  intelligent  care  should  make  impossible  of  occur- 
rence. It  is  hardly  too  much  to  say  that  in  nursing  the 
abuses  overbalance  the  usefulness  of  the  hot-water  bag. 

The  employment  of  the  hot-water  bag  should  be  covered 
by  strict  rules  with  which  each  nurse  should  be  made 
personally  acquainted.  The  following  are  suggested  by 
experience. 

First:  The  water  used  must  not  be  hot  enough  to  scald 
should  the  rubber  burst;  boiling-hot  water  will  also  injure 
the  rubber. 


HOT   APPLICATIONS  129 

Second:  The  bag  must  not  be  more  than  half  full,  and 
the  superfluous  air  must  be  pressed  out  before  the  screw 
top  is  adjusted. 

Third:  Every  bag  must  have  a  covering,  and  never,  on 
any  pretext,  be  given  to  a  patient  without  it. 

Fourth:  If  ordered  for  an  unconscious  patient,  a  blanket 
or  sheet  must  intervene  between  the  body  of  the  patient 
and  the  covered  hot-water  bag.  No  one  but  one  of  the 
nurses  (i.  e.,  neither  another  patient  nor  a  friend),  may 
place  it  in  position;  wherever  practical  it  should  be  a  rule 
that  a  second  nurse  is  called  to  overlook  the  proceeding 
and  pronounce  that  the  bags  are  in  proper  position. 

Fifth:  A  hot- water  bag  must  never  be  left  in  the  bed 
with  an  ether  patient  unless  by  a  special  written  order  of 
the  doctor,  covering  the  particular  case.  If  such  an 
order  has  been  given,  the  bags  are  placed  as  for  an  un- 
conscious patient,  and  the  patient  must  not  be  left  alone 
one  moment,  however  urgent  the  pretext,  as  long  as  the 
bags  are  in  the  bed. 

The  reason  for  such  a  stringent  rule  as  the  last  is  that 
an  ether  patient  is  usually  restless,  and  it  is  impossible  to 
place  the  bags  where  he  cannot  reach  them.  In  the  rest- 
less stage  he  is  in  a  semiconscious  condition  only,  and  the 
hot-water  bag  may  easily  rest  long  enough  against  his 
flesh  to  cause  a  deep  burn  without  his  being  aware  of  the 
fact.  There  are  instances  where  a  patient  has  been  kept 
in  a  hospital  many  weeks  after  complete  recovery  from 
his  operation  owing  to  burns  received  while  recovering 
from  ether.  That  he  should  bring  a  suit  for  damages 
against  an  institution  in  these  circumstances  is  not  sur- 
prising. 

The  hot-water  bag  is  used  for  restoring  the  general  bodily 
warmth  in  conditions  of  lowered  vitality  (several  bags  being 
placed  round  the  body  and  at  the  feet),  for  the  relief  of 
local  pain  and  inflammation,  and  to  counteract  the  depress- 
ing effect  on  the  circulation  of  cold  applied  to  the  body 
generally,  as  in  packing,  sponging,  etc.  When  used  as  a 
stimulant  to  the  general  circulation,  it  is  best  placed  at 
the  feet.  It  is  applied  to  the  perineum  or  over  the  bladder 
to  overcome  retention  of  urine. 


130 


LOCAL  APPLICATIONS 


For  restoring  the  bodily  warmth  the  hot-water  bag  can 
be  adequately  replaced  by  bricks  made  hot  in  the  oven  and 
protected  by  a  flannel  cover,  or  by  cans  or  bottles  filled 
with  hot  water.  The  same  precautions  must  be  observed 
in  their  use. 

Bran  Bag.  Salt  Bag. — Small  pillows  made  of  flannel  and 
filled  with  bran  or  salt  may  be  made  hot  in  an  oven  and 
used  as  a  soothing  application,  especially  in  neuralgic 
pain  of  the  face,  toothache,  or  earache.  They  retain  heat 
for  a  considerable  time.  A  second  bag  should  be  kept  in 
the  oven  to  replace  the  other  when  it  begins  to  cool. 


Fig.  16. — Pneumonia  jacket. 

Cotton  Jacket. — Raw  cotton,  heated  at  the  open  fire  or 
over  hot-water  pipes,  retains  the  heat  for  a  long  time,  and 
applied  with  a  flannel  bandage  affords  a  grateful  applica- 
tion for  faceache,  earache,  painful  glands,  etc.  Sewed  into 
a  "cotton"  or  "pneumonia  jacket"  (Fig.  16),  it  is  often  used 
as  a  matter  of  routine  treatment  in  cases  of  pneumonia,  es- 
pecially if  poultices  or  stupes  have  been  previously  ap- 
plied. The  pneumonia  jacket  is  made  of  cotton,  between 
two  layers  of  gauze  or  thin  muslin,  cut  to  fit  closely  to  the 
body,  with  arm-holes  and  shoulderpieces  so  as  completely 
to  cover  the  thorax.  One  side  is  left  open  and  is  fastened 
by  tapes  under  the  arm  and  over  the  shoulder.  The 


HOT  APPLICATIONS  131 

jacket  is  usually  lightly  quilted  to  keep  the  cotton  in  place 
(Fig.  16). 

When  it  is  desirable  to  wash  the  jacket,  it  should  be 
put  into  a  tub  of  suds,  not  too  hot,  and  kneaded,  never 
rubbed;  it  should  be  rinsed  thoroughly,  and  the  water 
squeezed  out  between  the  hands  instead  of  wrung,  well 
shaken,  and  quickly  dried. 

In  cases  of  pneumonia  the  value  of  a  cotton  jacket  is 
especially  in  protecting  the  skin  surface  from  chilling,  due 
to  changes  of  temperature. 

Thermostat. — A  patent  invention  consisting  of  a  rubber 
bag  (in  various  sizes)  containing  some  substances  which,  by 
a  chemical  process,  engender  heat  when  the  bag  is  lightly 
rubbed  up,  is  on  the  market  as  a  substitute  for  either  of 
the  above.  It  is  claimed  that  in  these  bags  heat  can  be 
retained  at  a  high  temperature  for  hours  and  even  days  at 
a  time.  The  invention  known  as  a  thermostat  is  hardly  as 
yet  perfected. 

MOIST  HEAT 

Poultices. — A  poultice  or  cataplasm  may  be  made  of 
any  substance  which,  when  parboiled,  is  capable  of  hold- 
ing heat  and  moisture.  The  most  satisfactory  poultice 
is  made  of  flaxseed  (linseed)  meal,  which,  on  account  of 
the  oil  it  contains,  retains  heat  for  a  longer  period  than 
such  substances  as  bread,  etc.  If  the  flaxseed  meal  is 
mixed  with  from  one-half  to  one-third  the  quantity  of 
bran,  an  equally  satisfactory  poultice  is  achieved  at  less 
cost. 

In  making  a  poultice  the  water  must  be  boiling,  the  basin, 
etc.,  used  heated  before  beginning,  and  all  required  at  hand, 
so  that  the  poultice  may  not  cool  during  the  preparation. 

Poultices  may  be  spread  on  old  muslin,  linen,  lint,  ab- 
sorbent cotton  (extravagant  except  for  fingers,  ears,  and 
other  minute  portions),  or  tow,  smoothly  pulled  into 
strands  which  readily  hold  together.  The  latter  is  pecu- 
liarly light,  inexpensive,  and  is  especially  useful  where  the 
poultice  is  applied  over  discharging  wounds,  as  free  drain- 
age is  not  impeded.  The  material  used  is  prepared  two 
inches  larger  than  the  required  poultice,  to  allow  for  turn- 
ing in  the  margins.  The  poultice  bowl  should  be  kept 


132  LOCAL   APPLICATIONS 


Figs.  17  and  18. — Making  a  poultice. 

entirety  for  such  a  use,  together  with  a  spatula  or  flexible 
knife  for  spreading  the  poultice. 


HOT   APPLICATIONS  133 

Sufficient  boiling  water  is  poured  into  a  heated  basin 
and  the  meal  run  in  quickly  through  the  fingers  of  the 
left  hand,  the  right  hand  stirring  all  the  time  with  the 
spatula.  When  the  mixture  is  cohesive  and  will  come  clean 
from  the  side  of  the  basin  or  drop  clean  from  the  spatula, 
it  is  of  the  right  consistency.  It  is  then  turned  on  to 
the  muslin  or  tow,  which  has  been  prepared  on  a  flat  board, 
such  as  a  pastry  board,  and  evenly  spread  with  the  spatula, 
dipping  the  spatula  in  boiling  water  once  or  twice  during 
the  process.  The  margins  are  turned  tidily  in  all  round 
and  the  poultice  rolled  up  in  a  warm  towel  and  carried  to 
the  patient  (Figs.  17,  18).  Before  applying  it  the  nurse 
should  hold  it  against  her  own  cheek  to  insure  its  not 
being  too  hot.  If  it  is  gradually  applied  to  the  patient's 
skin,  a  higher  temperature  can  be  borne  than  if  placed, 
all  at  once,  quickly  over  the  surface. 

A  poultice  that  does  not  contain  an  ingredient  irri- 
tating to  the  skin  should  be  applied  directly  to  the  skin 
surface ;  it  is  not  correct  to  cover  it  first  with  thin  muslin 
or  gauze,  which  absorbs  the  moisture  and  soon  becomes 
wet  and  uncomfortable.  In  order  to  retain  the  heat  and 
moisture  the  poultice,  when  in  place,  is  covered  with  a 
piece  of  thin  rubber  sheeting  (the  rubber  side  next  to  the 
poultice)  overlapping  the  poultice  one  inch  each  way, 
and  again  with  a  layer  of  cotton  overlapping  the  rubber 
covering.  It  is  kept  in  its  place  with  a  binder  or  a  bandage 
(see  Bandages,  Chap.  VIII).  For  application  to  the  ex- 
tremities, etc.,  poultices  may  be  spread  half  an  inch  thick 
or  more;  a  chest  poultice  should  not  be  more  than  a  quarter 
of  an  inch  thick,  while  those  for  the  abdomen  or  tender 
surfaces  should  be  spread  as  lightly  as  possible — not  more 
than  an  eighth  of  an  inch  thick. 

Except  over  wounds,  a  poultice  should  not  remain 
on  over  an  hour,  and  should  be  removed  even  sooner  if 
the  heat  is  not  retained.  A  cold  poultice  is  uncomfortable 
and  inefficacious.  On  removal,  the  surface  is  dried 
and  covered  with  a  layer  of  well-warmed  absorbent 
cotton,  which  is  left  on  until  the  next  poultice  is  applied, 
usually  at  regular  intervals  of  two,  three,  or  four  hours, 
according  to  circumstances.  If  the  skin  is  red, — and  it 


134  LOCAL   APPLICATIONS 

must  always  be  carefully  inspected, — an  application  of 
sweet  oil  or  vaselin  is  made,  and  if  another  poultice  is 
necessary,  the  poultice  itself  should  have  a  little  sweet 
oil  spread  over  its  entire  surface.  The  redness  should 
be  reported,  and  no  further  poultice  applied  without  fresh 
orders. 

As  a  treatment  in  pneumonia,  especially  in  the  lobular 
pneumonia  of  children,  poulticing  is  still  popular  with 
many  doctors,  though  not  nearly  so  common  as  fifteen  or 
twenty  years  ago.  If  continuous  treatment  is  required, 
it  is  usual  to  apply  the  poultices  alternately  to  the  front 
and  back  of  the  chest.  The  jacket  poultice  for  one  or  both 
lungs  should  cover  the  lung  entirely,  and  is  usually  best 
made  in  two  parts — that  for  the  front  is  shaped  like  the 
pattern  for  a  shirt-waist,  reaching  from  the  neck  to  the 
base  of  the  lung,  and  from  the  middle  line  of  the  chest  well 
over  the  shoulders  and  under  the  arms  toward  the  back. 
The  poultice  for  the  back  is  straight,  reaches  from  the  neck 
to  the  base  of  the  lung,  and  meets  the  front  poultice, 
overlapping  it  slightly.  The  jacket  poultice  is  kept  in 
place  by  a  wide  binder  of  flannel,  muslin,  etc.,  provided 
with  shoulder  straps  which  are  brought  over  the  shoulders 
and  pinned  in  front.  In  applying,  the  patient  should  lie  on 
the  side  of  the  sound  lung,  the  binder  already  in  place  and 
rolled  back  just  sufficiently  to  expose  the  surface  to  which 
the  application  is  to  be  made. 

To  aflaxseed  poultice  a  further  counterirritant  effect  may 
be  given  by  the  addition  of  mustard. 

Preparing  the  poultice  in  the  usual  way,  mustard  flour, 
broken  free  of  lumps,  may  be  stirred  into  the  poultice  just 
before  it  is  spread:  the  proportion  of  mustard  may  be 
from  one-tenth  to  one-sixth  of  the  whole.  The  active 
principle  of  mustard  is  a  volatile  oil,  the  properties  of 
which  are,  to  a  great  extent,  destroyed  by  boiling  water. 
A  poultice  containing  mustard  should  have  the  surface 
covered  with  a  thin  piece  of  muslin,  otherwise  there  is  a 
risk  of  particles  of  mustard  adhering  to  the  skin  and 
causing  burns  or  intense  irritation.  It  should  be  removed 
as  soon  as  the  skin  is  reddened,  a  corner  of  the  application 
being  raised  from  time  to  time  to  ascertain  the  condition. 


HOT   APPLICATIONS  135 

From  fifteen  minutes  to  half  an  hour  is  the  average  time 
such  a  poultice  is  retained,  unless  the  proportion  of  mus- 
tard is  very  small. 

A  soothing  or  anodyne  property  may  also  be  given  to  the 
flaxseed  poultice  by  sprinkling  over  the  surface  one  dram 
of  tincture  of  opium,  or  spreading  the  surface  of  the  poul- 
tice with  a  thin  layer  of  glycerin  and  belladonna  (official). 
Neither  should  be  used  over  a  broken  surface.  Although 
the  absorbent  power  of  the  unbroken  skin  is  not  great,  if 
such  a  poultice  is  used,  the  patient  must  be  watched  for 
symptoms  that  would  indicate  too  free  absorption  of  the 
drug.  The  absorbing  property  of  the  skin  is  considerably 
raised  by  the  moist  heat  of  the  application. 

One  of  the  actions  of  moist  heat  being  to  encourage 
suppuration,  the  poultice  may  be  used  to  hasten  the  sepa- 
ration of  foul-smelling  sloughs  or  gangrenous  tissues  from 
wounds.  The  flaxseed  poultice  is  usually  used  frequently 
mixed  with  one-sixth  part  of  powdered  wood-charcoal, 
which  acts  as  a  deodorizer.  The  charcoal  is  stirred  in 
just  before  spreading  and  well  mixed.  A  charcoal  poul- 
tice is  applied  directly  to  the  surface  of  the  wound  with- 
out the  covering  of  muslin  necessary  in  a  mustard  poultice. 
At  the  present  day  poulticing  is  net  a  common  treatment 
for  wounds. 

Oatmeal,  wheatmeal,  ground  corn,  and  such  vegetables 
as  carrots,  peas,  beans,  etc.,  may  be  used  to  make  poultices 
where  flaxseed  is  not  procurable.  They  should  be  cooked 
until  soft  and  all  superfluous  moisture  then  drained  away, 
when  they  can  be  spread  the  required  thickness  and  applied. 
Being  more  apt  to  stick  to  the  skin  than  flaxseed,  the 
surface  of  the  poultice  should  be  spread  with  warm 
sweet  oil  and  covered  with  a  layer  of  thin  muslin.  If 
an  onion  is  used,  it  is  boiled  until  it  falls  apart,  or  cut  into 
slices,  fried,  and  applied  while  hot. 

A  bread  poultice  is  prepared  by  placing  a  thick  slice  of 
bread  on  a  board  or  over  a  sieve,  and  pouring  on  it  boiling 
water  until  it  is  sufficiently  soft.  The  board  is  held  so 
that  the  water  can  run  off  into  a  basin  or  sink.  The  bread 
is  then  spread  on  muslin  and  applied,  usually  directly  to 
the  surface.  This  is  entirely  a  domestic  remedy  and  not 


136  LOCAL   APPLICATIONS 

greatly  efficacious.  It  is  a  favorite  method  of  drawing 
splinters  from  fingers. 

Soap  Poultice. — A  soap  poultice  is  used  for  its  cleansing 
effects.  It  may  be  applied  to  portions  of  the  body  difficult 
to  cleanse,  such  as  the  heels,  palms  of  the  hands,  or  the 
umbilicus;  or  to  soften  and  remove  the  crusts  of  ringworm 
or  scabs  of  neglected  wounds.  It  should  not  be  used  to 
remove  scabs  due  to  skin  diseases  other  than  ringworm. 
A  piece  of  clean,  soft  old  muslin  is  soaked  in  tincture  of 
green  soap  (warmed)  and  applied  directly  to  the  part. 
The  poultice  is  covered  with  gutta-percha  tissue,  etc., 
cut  Pto  overlap  an  inch  in  all  directions,  and  kept  in 
place  with  a  bandage.  It  should  be  changed  before 
becoming  dry,  but  usually  it  is  sufficient  to  change  the 
poultice  night  and  morning  until  the  desired  result  is 
attained. 

Oil  Poultice. — Muslin  or  gauze  soaked  in  warm  sweet 
oil  may  be  used  instead  of  the  soap  poultice,  for  the  same 
purposes,  and  applied  in  the  same  manner. 

Starch  Poultice. — A  starch  poultice  is  made  of  laundry 
starch  cooked  in  the  usual  way,  i.  e.,  mixed  to  a  paste 
with  cold  water,  and  sufficient  boiling  water  added  to 
bring  it  to  the  required  consistence.  It  is  spread  about 
half  an  inch  thick  between  two  folds  of  muslin  and  covered, 
like  the  soap  poultice,  with  some  protective  when  in  place. 
It  may  be  applied  hot  or  just  warm,  according  to  cir- 
cumstances. It  is  ordered  in  some  skin  affections  for 
removing  scabs  and  crusts  and  to  allay  itching.  It  is 
applied  directly  to  the  part. 

Poultice  of  Digitalis  Leaves. — A  poultice  of  dried  digi- 
talis (foxglove)  leaves  is  sometimes  ordered  in  cases  of 
nephritis,  applied  over  the  loins  to  stimulate  the  activity 
of  the  kidneys.  To  the  leaves  sufficient  hot  water  is 
added  to  barely  cover  them,  and  they  are  allowed  to  sim- 
mer gently  until  soft  enough  to  break  into  pulp.  The  pulp 
may  be  spread  between  two  folds  of  muslin  and  applied 
to  the  surface,  or  may  be  incorporated  with  a  flaxseed 
poultice  in  the  same  manner  as  mustard  or  charcoal. 
The  water  in  which  they  are  cooked  should  be  used  in 
mixing  the  poultice. 


HOT   APPLICATIONS 


137 


Stupes  or  Fomentations. — A  stupe  or  fomentation 
affords  a  clean,  economical,  and  efficient  method  of  ap- 
plying local  heat.  It  consists  of  two  or  more  layers  of 


soft  old  flannel  or  blanket  wrung  as  dry  as  possible  out 
of  boiling  water,  applied  directly  to  the  skin,  and  cov- 
ered, to  retain  the  heat  and  moisture,  with  a  piece  of 
light  rubber  sheeting  at  least  an  inch  larger  in  each  direc- 


138  LOCAL   APPLICATIONS 

tion  than  the  stupe,  and  again  with  a  pad  of  absorbent 
cotton;  the  whole  kept  in  its  place  by  a  binder  or  bandage. 

To  prepare,  a  wringer  and  a  fairly  deep  basin  are  re- 
quired (Figs.  19,  20).  The  wringer  is  best  made  of  one 
and  one-half  yards  of  stout  roller  toweling,  the  ends  sewn 
together.  This  forms  a  double  wringer  three-quarters  of  a 
yard  long.  It  is  laid  open  in  a  well-warmed  basin,  the 
ends  hanging  over  the  sides;  on  it,  at  the  bottom  of  the 
basin,  is  placed,  folded,  the  dry  flannel.  Boiling  water  is 
then  poured  on,  the  sides  of  the  wringer  are  folded  over  the 
flannel,  and  the  ends  grasped  and  twisted  firmly  in  oppo- 
site directions  until  all  the  water  is  wrung  out  of  the  stupe. 
If  managed  with  any  care,  the  ends  are  easily  kept  dry, 
and  the  stupe  sticks,  so  often  advocated,  are  not  necessary. 
If  the  stupe  has  to  be  carried  any  distance,  it  should  be 
wrung  out  at  the  bedside,  as  it  rapidly  cools.  Great  care 
must  be  taken  that  the  stupe  is  wrung  really  dry,  if  not,  the 
patient  may  be  scalded.  It  should  be  shaken  a  moment 
or  two  in  the  air  before  applying,  to  let  the  steam  escape. 

Where  a  stupe  is  ordered  over  a  broken  surface,  sterile 
gauze  instead  of  flannel  is  used,  and  a  sterile  towel  may 
serve  as  a  wringer.  An  antiseptic  solution  is  often  pre- 
ferred to  the  plain  boiling  water.  Such  a  stupe  is  a  surgical 
dressing,  and  the  same  strict  asepsis  must  be  observed  in 
applying  it  as  in  any  other  variety  of  dressing. 

Stupe  as  a  Counterirritant. — Turpentine  sprinkled 
over  the  stupe  is  a  common  form  of  the  mild  counter- 
irritant.  One  to  two  drams  of  household  turpentine 
(measured)  is  freely  sprinkled  over  the  dry  flannel  on  the 
surface  which  is  to  be  next  the  patient.  The  flannel  is 
then  folded  and  the  stupe  prepared  in  the  usual  way.  In 
sprinkling  before  the  water  is  added  there  is  less  risk  of 
the  turpentine  collecting  in  one  or  two  spots,  an  accident 
which  may  cause  a  troublesome  burn.  The  turpentine 
stupe  is  frequently  used  for  the  relief  of  intestinal  disten- 
tion.  It  is  useless  in  the  true  abdominal  tympanites  of 
peritonitis  except  to  soothe  pain. 

Sedative  Stupe. — Tincture  of  opium,  belladonna,  or 
infusions  of  poppy  heads  are  sometimes  added  to  the  stupe 
when  it  is  used  for  the  relief  of  acute  local  pain,  such  as 


HOT   APPLICATIONS  139 

over  painful  glands  or  for  earache,  where  the  skin  surface 
is  unbroken.  Tincture  of  opium,  one  to  two  drams,  is 
freely  sprinkled  on  the  prepared  stupe  immediately  before 
applying.  By  this  method  none  of  the  drug  is  lost  in  the 
water  used  for  the  stupe. 

Belladonna  and  glycerin  (the  official  preparation)  is 
spread  thickly  over  the  flannel  before  the  water  is  added. 
A  second  method  is  to  spread  the  belladonna  and  glycerin 
on  a  piece  of  lint,  apply  it  first  to  the  part,  and  over  it  a 
plain  stupe. 

Medicated  stupes  are  prepared  by  using  an  infusion  of 
a  raw  substance  containing  a  drug  in  the  place  of  plain 
boiling  water.  Digitalis  leaves  and  the  heads  of  the  white 
poppy,  from  which  opium  is  obtained,  may  be  used  in 
this  way. 

Digitalis  Stupe. — To  the  dried  leaves  is  added  sufficient 
boiling  water  to  cover  them,  they  are  kept  simmering 
until  soft,  then  broken  up  with  a  fork  and  allowed  to 
cool.  When  cool,  the  fluid  is  strained,  heated  to  scalding 
point,  but  not  boiled,  and  used  for  the  stupe.  It  is  used 
for  the  same  purpose  as  the  digitalis  poultice. 

Poppy-head  Stupe. — To  two  dried  poppy  heads  is 
added,  a  pint  of  boiling  water.  The  capsule  should  be 
freely  slit  with  a  sharp  knife  before  adding  the  water. 
The  heads  should  simmer  until  soft,  then  stand  until 
cool,  when  the  fluid  is  strained,  heated  to  scalding  point, 
and  used  for.  the  stupe.  It  is  employed,  though  not  very 
commonly,  to  relieve  the  pain  of  earache,  neuralgia,  or 
enlarged  glands. 

Alkaline  Stupe. — Sufficient  washing-soda  (or  bicarbon- 
ate of  soda)  may  be  added  to  the  stupe  water  to  give  it 
a  strong  alkaline  reaction,  and  the  stupe  is  prepared  in 
the  usual  manner.  The  alkaline  stupe  is  a  homely  remedy 
for  painful  joints  in  chronic  and  subacute  rheumatism,  and 
often  appears  to  give  great  relief.  When  no  litmus  paper 
is  at  hand  to  test  the  reaction,  sufficient  soda  to  give  the 
water  a  slippery  feeling  is  the  indication. 

When  a  poultice  or  stupe  is  discontinued,  the  part  should 
be  covered  for  a  time  with  a  piece  of  absorbent  cotton  or 
flannel. 


140  LOCAL   APPLICATIONS 

HOT   COMPRESSES 

Hot  compresses  are  frequently  ordered  as  an  eye  appli- 
cation, especially  in  inflammatory  conditions  caused  by 
wounds  from  foreign  bodies.  Except  that  the  compresses 
are  wrung  out  of  hot  water,  they  are  applied  in  the  same 
way  as  cold  compresses.  The  water  may  be  kept  at  a 
correct  temperature  by  placing  the  basin  over  an  alcohol 
lamp,  Bunsen  burner,  or  electric  heater.  The  compresses 
are  applied  as  dry  as  possible  and  as  hot  as  can  be  borne 
without  scalding  the  eyelids.  The  hand  should  be  pro- 
tected by  a  rubber  glove,  or  a  wringer  may  be  made  of  a 
small  piece  of  sterile  muslin,  to  each  end  of  which  a  pair 
of  artery  forceps  is  clipped;  by  twisting  these  in  opposite 
directions,  the  compress  is  efficiently  wrung.  The  appli- 
cation is  frequently  ordered  for  from  ten  to  twenty  minutes 
at  regularly  repeated  intervals.  Between  the  intervals 
the  lids  may  be  smeared  with  sterile  vaselin  or  albolene. 

COUNTERIRRITANTS 

Counterirritants  are  divided  into  rubefacients,  those 
that  redden  the  skin  surface;  vesicants  or  epispastics,  those 
that  produce  a  blister  or  exudation  of  serum  between  the 
cuticle  and  the  dermis;  and  escharotics,  those  that  destroy 
the  soft  tissues  and  cause  sloughing.  A  vesicant  that, 
instead  of  a  clear  blister,  causes  a  pustule  or  milky  exudate 
is  also  called  a  pustulant.  A  pustule  contains  serum 
and  white  corpuscles,  takes  longer  to  heal,  and  is  more 
liable  to  cause  a  scar  than  the  clear  blister,  which  heals 
quickly  and  leaves  no  scar. 

RUBEFACIENTS 

Heat. — Heat  in  many  of  the  applications  mentioned 
above  may  also  correctly  be  considered  as  a  rubefacient; 
this  is  especially  the  case  where  it  is  employed  in  com- 
bination with  a  counterirritant,  as  in  the  mustard 
poultice  or  the  turpentine  stupe,  both  of  which  are,  prop- 
erly speaking,  Counterirritants  and  in  common  use. 

Sinapisms  or  Plasters  of  Mustard. — Mustard  Paste. — 
A  paste  is  made  of  flour  and  warm  water,  into  which  is 
stirred  a  proportion  of  mustard,  broken  free  of  lumps.  The 


RUBEFACIENTS  141 

proportion  of  mustard  (powder)  varies  from  an  eighth  to  a 
half.  The  half-in-half  paste  is  used  when  only  one  appli- 
cation is  desired,  as,  for  instance,  when  applied  to  the  chest 
to  help  in  breaking  up  a  bronchial  "  cold."  The  usual  pro- 
portion is  one  part  of  mustard  in  four  of  flour  for  an  adult, 
and  in  from  six  to  ten  parts  of  flour  for  a  young  child. 
The  paste  is  spread  on  thick  muslin  and  the  edges  turned 
over;  the  surface  next  the  skin  is  covered  with  gauze  or 
thin  muslin.  It  may  be  left  on  for  from  five  minutes  to  a 
quarter  of  an  hour,  a  corner  being  raised  from  time  to 
time  to  watch  the  results,  and  the  sinapism  removed  as 
soon  as  the  skin  is  well  reddened.  If  the  skin  is  easily 
affected,  as  in  children,  the  white  of  one  egg  may  be  mixed 
with  the  paste  or  a  little  sweet  oil  spread  over  the  surface. 
It  must  be  remembered  that  mustard  is  not  a  counterirri- 
tant  in  the  dry  form.  Its  active  principle  or  irritating 
property  is  contained  in  a  volatile  oil  set  free  only  on  the 
addition  of  water.  This  is  easily  demonstrated  by  smelling 
mustard  before  and  after  water  is  added.  Where  very 
hot  or  boiling  water  is  used,  much  of  the  active  property 
is  destroyed,  as  also  where  vinegar  is  used  to  mix  it,  as  in 
"  French  mustard." 

An  official  preparation  known  as  the  mustard-leaf  is 
a  simple  method  of  using  mustard  as  a  counterirritant. 
Cut  to  the  required  size,  the  leaf  is  dipped  in  tepid  water, 
allowed  to  drip  for  a  moment  or  two,  and  applied  directly 
to  the  skin  surface,  or,  if  the  skin  is  delicate,  with  a  layer 
of  thin  muslin  between.  It  cannot  usually  be  borne  more 
than  for  from  four  to  eight  minutes. 

After  the  removal  of  a  mustard  paste  or  mustard-leaf, 
warm,  dry  cotton  or  a  soft  handkerchief  should  be  kept 
on  the  part  until  the  redness  has  disappeared.  If  deeply 
reddened,  an  application  of  sweet  oil  or  vaselin  may  be 
made.  A  sinapism  should  not  be  left  on  long  enough  to 
cause  a  blister. 

Among  the  laity  the  mustard-leaf  is  sometimes  prepared 
by  dipping  it  in  whisky,  in  order,  it  is  believed,  to  make  it 
a  yet  more  active  counterirritant.  This  is  incorrect,  as 
alcohol  actually  prevents  the  volatile  oil,  which  contains 
the  active  principle  of  mustard,  from  being  set  free. 


142  LOCAL  APPLICATIONS 

Spice  Poultice. — This  is  a  form  of  mild  counter-irritant 
not  met  with  in  modern  nursing,  but  still  used  among  old- 
fashioned  people  to  relieve  the  pain  of  muscular  rheuma- 
tism, especially  lumbago.  The  poultice  is  made  of  one- 
half  the  quantity  of  flour,  the  other  half  of  equal  parts  of 
various  spices,  cloves,  allspice,  ginger,  cinnamon  (pow- 
dered), with  a  smaller  proportion  of  either  capsicum  or 
Cayenne  pepper.  The  flour  is  first  made  into  a  paste  with 
hot  whisky,  the  spices  stirred  in,  and  the  Cayenne  pepper 
or  capsicum  sprinkled  over  the  surface.  The  poultice 
is  spread  on  muslin  and  the  surface  covered  with  gauze. 
It  may  be  kept  on  as  long  as  comfortable. 


Fig.  21. — Cupping.     First  step,  swabbing  the  interior  of  the  cupping 
glass  with  alcohol  (Morrow). 

Dry  Cupping. — For  cupping,  a  set  of  glass  cups,  five  to 
seven  in  number,  are  used.  Special  rimmed  cups  of  thick 
glass  with  a  capacity  of  from  one  to  four  ounces  are  used, 
but  any  glass  of  convenient  size  may  be  substituted. 
The  inside  of  the  cup  is  rubbed  over  with  a  little  cot- 
ton sponge  soaked  in  alcohol,  the  sponge  conveniently 
mounted  on  a  small  applicator;  to  the  cup  a  light  is  then 
applied,  the  alcohol  flames  up,  and  in  so  doing  exhausts 
entirely  the  air  in  the  cup.  The  rim  of  the  cup  should 
be  wet  with  water  to  prevent  it  becoming  so  hot  as  to  burn 
the  skin.  Just  before  the  flame  dies  out  the  cup  is  quickly 
inverted  over  the  affected  area,  to  which  it  will  readily 


RUBEFACIENTS 


143 


Fig.  22. — Cupping.     Second  step,  igniting  the  alcohol  in  the  cup- 
ping glass  (Morrow). 


Fig.  23. — Cupping.     Third  step,  the  application  of  the  cups 
(Morrow). 

adhere.     The  skin  and  tissues  covered  by  the  cup  are 
drawn  up  into  the  vacuum,  the  superficial  blood-vessels 


144 


LOCAL   APPLICATIONS 


become  greatly  dilated,  bringing  an  increased  quantity  of 
blood  to  the  surface.  Five  to  seven  cups  are  usually 
applied  at  one  time,  and  left  in  place  until  the  skin  is  well 
reddened.  To  remove  a  cup,  the  tip  of  the  finger  is 
inserted  under  the  rim;  air  being  then  admitted,  the  cup 
is  no  longer  adherent  (Figs.  21-24). 

Wet  Cupping. — If,  before  the  application  of  the  cups, 
several  incisions  with  a  sharp  knife  are  made  over  each 
space,  blood  will  be  drawn  from  the  tissues  into  the  vacuum 
when  the  cups  are  in  place.  The  process  is  known  as 
wet  cupping.  The  skin  should  previously  be  prepared 


Fig.  24. — Instruments  for  wet  cupping:  1,  Cupping  glasses;  2,  swab 
in  alcohol;  3,  alcohol  lamp;  4,  scalpel  (Morrow). 

by  scrubbing  with  sterile  soap  and  water,  shaving  if 
necessary,  and  washed  with  bichlorid  of  mercury.  On 
account  of  their  inflammable  qualities  neither  alcohol  nor 
ether  should  be  used  in  the  preparation  of  Ihe  skin,  as  if 
not  entirely  removed,  the  skin  may  be  burned.  On  removal 
of  the  cups  the  parts  are  covered  with  a  sterile  dressing, 
the  blood  withdrawn  carefully  measured,  and  note  made 
of  the  quantity. 

Cupping  is  used  chiefly  in  the  treatment  of  pneumonia, 
acute  nephritis,  or  edema  of  the  lungs,  to  which  end  they 
are  best  placed  on  the  flat  surface  of  the  back  or  loins, 


RUBEFACIENTS  145 

Wet  cupping  may  also  be  used  in  the  treatment  of  inflam- 
matory conditions  of  the  eye  or  ear,  small-sized  glasses 
being  applied  over  the  temple  or  behind  the  ear.  Where 
they  can  be  procured,  leeches  are,  however,  preferred. 

Leeching. — While  not  a  rubefacient,  leeching  may 
conveniently  be  considered  in  this  group.  The  leech,  or 
hirudo,  is  a  blood-sucking  worm  found  in  the  ponds  and 
marshlands  of  special  districts.  Those  used  in  medicine 
usually  come  from  Sweden,  those  native  to  America  being 
considered  to  have  only  one-sixth  the  strength  of  the  Swe- 
dish leech.  Until  ready  for  use  they  should  be  kept  in  a 
jar  of  clean  fresh  water,  with  some  sand  at  the  bottom, 
closely  covered  with  a  perforated  top. 

As  a  leech-bite  is  liable  to  bleed,  care  must  be  taken  to 
apply  the  leech  to  such  parts  as  can  readily  have  pressure 
applied  to  them.  The  temple  or  forehead,  for  example,  is 
used  in  applying  leeches  to  relieve  inflammatory  conditions 
of  the  eye  and  not  the  eyelids. 

The  skin  is  prepared  by  washing  with  unscented  soap, 
rinsing  thoroughly  with  water,  and  drying  with  sterile 
cotton.  If  necessary,  as  behind  the  ear,  the  part  must  be 
shaved.  Disinfectants  or  applications  with  an  odor  to 
them  will  prevent  the  leech  biting.  The  leech  may  be 
held  in  a  piece  of  gauze,  but  usually  will  bite  more  quickly 
if  placed  in  a  test-tube  which  is  inverted  over  the  spot. 
Care  must  be  taken  to  apply  the  head,  and  not  the  tail 
of  the  animal.  The  head  is  recognized  by  the  three-corn- 
ered or  Y-shaped  mouth  peculiar  to  the  leech. 

If  the  leech  does  not  bite,  he  is  usually  hot,  uncomfort- 
able, and  irritable,  probably  from  having  been  kept  out  of 
water.  He  may  be  coaxed  by  smearing  the  part  with 
milk,  or  by  pricking  the  part  until  a  drop  of  blood  comes, 
or  by  gently  stroking  his  back,  but  if  still  obstinate,  it  is 
quicker  eventually  to  return  him  for  a  time  to  the  water, 
and  allow  him  to  cool  himself  off  in  a  dark  place.  A  leech 
will  frequently  refuse  to  bite  if  the  atmosphere  of  the  room 
is  heavy  with  tobacco  or  disinfectants,  etc. 

The  Swedish  leech  will  draw  from  half  an  ounce  to  an 
ounce  of  blood,  the  American  about  a  sixth  as  much. 
When  full,  he  will  drop  off,  and  is  then  usually  destroyed 
10 


146  LOCAL   APPLICATIONS 

by  covering  him  with  salt  and  burned.  He  should  not  be 
thrown  alive  down  the  soil-pipe.  If  it  is  desired  to  remove 
a  leech  while  sucking,  he  is  sprinkled  with  a  little  table- 
salt.  He  should  never  be  pulled  off,  as  the  teeth  are  then 
liable  to  be  left,  causing  hemorrhage,  slight  but  difficult  to 
control,  and  subsequent  inflammation.  After  removal, 
if  there  is  no  hemorrhage,  a  minute  dressing  of  gauze  and 
collodion  (p.  513)  is  applied.  If  there  is  any  tendency  to 
bleed,  a  dry  graduated  compress  (p.  598)  may  be  tightly 
bandaged  over  the  part,  and  if  obstinate,  ice  compresses 
or  some  styptic,  such  as  alum,  tannic  acid,  etc.,  is  also 
applied.  Occasionally  a  further  quantity  of  blood  is 
withdrawn  by  applying  poultices  to  the  bite  after  the  leech 
is  removed.  A  patient  to  whom  a  leech  is  applied  should 
not  be  left  alone.  If,  for  any  reason,  this  is  inevitable, 
the  ears  and  nostrils  should  be  plugged  with  absorbent 
cotton  in  case  of  the  leech  straying. 

Many  patients  object  to  the  sensation  of  the  leech's 
body;  this  can  be  obviated  by  placing  a  fold  of  gauze  or 
handkerchief  under  the  leech  once  he  is  seen  to  be  holding 
firmly. 

Leeches  are  most  commonly  employed  in  inflammatory 
conditions  of  the  eye  or  ear,  and  are  applied  to  the  temple, 
forehead,  or  behind  the  ear.  They  are  also,  though  not 
so  frequently,  applied  behind  the  ear  to  relieve  cerebral 
congestion,  and  over  the  pericardium  in  the  treatment  of 
acute  pericarditis.  In  gynecologic  work  they  are  some- 
times applied  to  the  cervix  uteri ;  this  is,  however,  never 
left  to  the  nurse. 

Tincture  of  lodin. — Tincture  of  iodin,  painted  on  the 
skin  surface,  is  used  as  a  mild  counterirritant  in  many 
conditions,  especially  those  in  which  it  is  desirable  to  check 
the  formation  of  effusions,  as  in  pleurisy  or  inflammation 
of  a  synovial  membrane.  It  is  also  generally  used  in  the 
treatment  of  enlarged  glands.  It  is  of  little  value  for  the 
relief  of  acute  pain. 

The  amount  required  for  one  application  is  poured  in  a 
small  saucer  and  painted  quickly  (it  evaporates  on  stand- 
ing) on  the  surface  with  a  camel's-hair  brush,  care  being 
taken  not  to  allow  the  application  to  run  beyond  the 


KUBEFACIENTS  147 

specified  area.  If  necessary,  this  can  be  prevented  by 
previously  outlining  the  space  with  sweet  oil  or  vaselin. 
A  light  application  stains  the  skin  yellow;  usually  the 
iodin  is  applied  until  a  mahogany  hue  is  reached.  Each 
layer  should  be  dry  before  the  next  is  applied.  It  should 
not  be  applied  sufficiently  thickly  to  cause  a  blister. 
For  the  same  reason  the  surface  should  be  painted  evenly— 
not  too  thickly  on  one  spot.  Usually  the  application  is 
made  two  or  three  times  at  intervals  of  twenty-four  hours. 
If  a  mistake  has  been  made  and  too  much  applied,  it  can 
be  removed  with  alcohol. 

The  painted  area  should  be  covered  with  a  piece  of 
muslin  or  a  bandage  to  protect  the  linen  from  staining. 
If  a  stain  occurs,  it  should  be  removed  before  washing  by 
covering  with  a  paste  made  of  raw  starch  and  alcohol. 

Ironing. — Ironing  the  surface  as  a  remedy  for  pain, 
especially  that  of  muscular  rheumatism,  is  not  often 
ordered  in  hospital  work,  but  is  a  common  remedy  in 
home  nursing. 

The  painful  surface  is  covered  with  a  piece  of  thick 
paper,  just  above  which  a  hot  laundry  iron  is  repeatedly 
passed  until  the  skin  is  reddened.  The  iron  must  not  be 
pressed  down  on  the  paper. 

The  Actual  Cautery. — Cauterization,  or  the  searing  of 
the  flesh,  is  a  form  of  counterirritant  which  may  be  rube- 
facient,  vesicant,  or  escharotic,  according  to  the  degree 
employed. 

The  instrument  generally  used  in  medical  practice  is 
the  Paquelin  cautery,  though  a  metal,  such  as  iron  or  steel, 
capable  of  sustaining  a  high  degree  of  heat,  may  be  sub- 
stituted in  any  practical  form.  The  Paquelin  cautery 
consists  of  a  hollow,  flattened  tip  of  platinum,  which  is 
screwed  on  to  a  small  metal  cylinder,  or  connected  by  a 
rubber  tube  with  a  bottle,  either  containing  a  small  quantity 
of  benzene.  Attached  to  the  cylinder  or  bottle  is  an  air- 
pump,  by  working  which  the  fumes  of  benzene  are  blown 
into  the  tip.  If  the  tip  is  previously  heated  over  an  alco- 
hol lamp,  the  fumes  will  ignite  inside  the  hollow  tip  and 
maintain,  by  this  simple  process,  the  tip  at  the  required 
degree  of  heat.  The  air-pump  consists  of  a  length  of 


148  LOCAL  APPLICATIONS 

rubber  tubing  fitted  with  two  rubber  balls,  one  hard  and 
one  soft,  the  soft  one  being  protected  from  overdistention 
by  a  netting  of  strong  silk.  The  hard  bulb  is  squeezed 
from  time  to  time,  thus  pumping  air  into  the  soft  bulb, 
which  acts  as  a  reservoir,  and  simply  from  the  effect  of 
atmospheric  pressure  passes  the  air  in  a  steady  current  over 
the  benzene.  By  keeping  the  soft  bulb  moderately  dis- 
tended, sufficient  force  of  air  and  benzene  is  blown  into  the 
tip  to  keep  it  at  a  steady  heat.  Very  little  benzene  is  re- 
quired; usually  the  required  amount  is  soaked  up  on  a 
small  sponge  or  absorbent  cotton  and  placed  in  the  bottom 
of  the  cylinder  or  bottle.  If  too  much  is  used,  the  benzene 


Fig.  25. — Paquelin's  cautery.     Note  that  the  benzene  is  contained 
in  the  handle  of  the  apparatus  (W.  E.  Ashton). 


itself  may  ignite  and  cause  an  explosion.  The  cautery  is 
generally  used  just  below  red  heat.  After  use  the  tip 
should  be  brought  to  white  heat  for  a  few  moments,  in 
order  to  burn  off  any  shreds  of  tissue  which  may  adhere. 
While  cooling,  it  should  be  kept  in  a  safe  place.  It  should 
be  allowed  to  cool  slowly,  and  when  quite  cold,  may  be 
washed  and  cleaned  like  other  instruments.  The  platinum 
tips  are  very  costly,  platinum  being  a  more  highly  priced 
metal  than  gold;  they  require  the  greatest  care  in  handling, 
as  when  heated,  the  smallest  knock  or  fall  will  dent  them, 
thus  destroying  the  even  surface  necessary.  For  this 
reason  the  cautery  should  always  be  in  charge  of  a  reliable 


VESICANTS  149 

nurse,  but  every  pupil  should  be  taught  how  to  put  it 
together  for  use  and  the  proper  care  of  the  different  parts. 

In  hospitals  and  doctors'  offices  a  modification  of  the 
Paquelin  cautery  is  now  often  found,  the  platinum  tip 
being  screwed  on  to  a  convenient  handle  connected  with 
an  electric  current.  Where  the  heat  is  supplied  by  elec- 
tricity, it  is  not  necessary  to  heat  the  tip,  in  the  first 
place,  over  an  alcohol  flame. 

The  cautery  is  employed  for  the  relief  of  pain,  especially 
that  of  muscular  rheumatism,  to  promote  the  absorption 
of  inflammatory  products,  and  for  the  arrest  of  hemorrhage 
from  any  vascular  surfaces,  as,  for  instance,  after  the  use 
of  the  clamp  in  operations  for  hemorrhoids.  As  an  eschar- 
otic  it  is  used  in  surgery  as  an  application  to  wounds 
when  it  is  desirable  to  destroy  the  superficial  tissue.  To 
cauterize  was,  until  recently,  the  classic  treatment  for  all 
wounds  caused  by  the  bites  of  animals,  dogs,  cats,  ser- 
pents, etc.  At  the  present  day  it  is  less  in  favor,  free 
incision  being  generally  preferred. 

If  a  nurse  is  directed  to  disinfect  the  skin  before  cauter- 
ization, she  should  understand  to  do  so  only  with  soap  and 
water  and  a  disinfectant  solution.  Alcohol  and  ether  must 
be  avoided,  as,  on  account  of  their  inflammable  proper- 
ties, an  accident  might  happen  if  they  had  not  been  thor- 
oughly removed. 

VESICANTS 

This  form  of  counterirritation  is  most  generally  em- 
ployed where  it  is  desirable  to  check  the  formation  of 
effusion,  as  in  pleurisy,  pericarditis,  or  synovitis  of  one  of 
the  joints.  Blistering  may  be  accomplished  by  using  a 
rubefacient  in  a  more  concentrated  form  or  over  a  longer 
period,  but  most  commonly  a  preparation  of  a  Spanish 
fly,  cantharides,  is  employed.  It  may  be  obtained  in  the 
form  of  a  fluid,  an  ointment,  or  a  plaster.  Where  the 
order  to  "  apply  a  blister  "  is  given,  cantharides  is  under- 
stood. 

Before  applying  a  blister  the  skin  should  be  carefully 
cleaned  with  soap  and  water,  alcohol  or  ether,  and  a  dis- 
infectant, shaving,  when  necessary,  in  order  that  the  ap- 
plication may  act  the  more  readily,  and  that  the  area  may 


150  LOCAL   APPLICATIONS 

be  aseptic  when  the  blister  is  opened.  The  site  chosen 
should  be  over  a  well-covered  surface,  plentifully  supplied 
with  blood-vessels,  and  not  over  a  bony  prominence,  where 
healing  would  be  slow. 

The  blister  is  always  a  small  application,  usually  one  to 
two  inches  square.  This  is  both  on  account  of  the  des- 
truction of  tissue,  and  because  of  the  poisonous  effect  of 
the  drug,  which,  when  absorbed  too  freely  into  the  system, 
causes  acute  nephritis.  The  symptoms  of  cantharidal 
poisoning  are  headache,  vomiting,  fever,  and  scanty  urine, 
containing  albumin  (p.  279). 

Cantharidal  Collodion  or  Blistering  Fluid. — The  canthar- 
idal collodion  is  painted  on  the  skin  with  a  camel's-hair 
brush.  In  order  to  keep  exactly  to  the  required  size  and 
prevent  the  fluid  running,  the  space  may  be  outlined  first 
with  sweet  oil  or  vaselin.  Allowing  a  very  few  moments 
for  the  application  to  dry,  the  blister  is  then  covered  with 
gauze  and  finally  with  waxed  paper,  or  some  convenient 
protective,  and  a  bandage  applied  lightly,  in  order  to  allow 
for  the  rising  of  the  blister. 

Cantharides  Plaster. — The  plaster  is  cut  to  the  required 
size  and  applied  directly  to  the  surface;  it  is  held  in  po- 
sition with  a  lightly  applied  bandage. 

Cantharidal  ointment  or  cerate  is  also  applied  directly 
to  the  surface,  the  application  being  first  spread  on  muslin 
or  lint.  It  is  not  so  reliable  a  preparation  as  either  the 
plaster  or  the  collodion. 

After  either  of  the  above  forms  of  application  the  area 
must  be  examined  from  time  to  time  to  ascertain  if  the 
blister  has  risen.  From  four  to  eight  hours  is  usually 
required  to  form  the  single  large  bleb  desired.  If  it  has 
not  formed  at  the  end  of  eight  hours,  the  application  should 
be  removed  and  a  poultice  or  a  hot  fomentation  applied 
to  the  site.  These  should  not  be  applied  over  the  appli- 
cation itself,  as  sloughing  and  symptoms  of  poisonous 
absorption  may  result.  With  young  children  a  blister  is 
best  removed  as  soon  as  the  skin  is  thoroughly  reddened, 
and  a  poultice  applied  until  the  blister  has  formed. 

The  collodion  or  ointment  may  be  removed  with  ether. 

When  the  blister  is  well  risen,  it  is  opened  and  dressed 


VESICANTS  151 

with  strict  aseptic  precautions.  In  opening,  a  snip  is 
made  at  the  most  dependent  point  of  the  blister,  and  the 
fluid  gently  pressed  out  on  a  piece  of  sterile  cotton.  A  dry 
sterile  dressing  is  usually  applied,  and  either  changed  every 
day  or  left  in  place  until  the  blister  is  healed,  or  a  daily 
dressing  of  boric  ointment  may  be  preferred.  In  some 
instances  the  blister  is  left  uncut,  and  the  fluid  allowed 
to  be  reabsorbed.  In  this  case  it  is  covered  with  a 
dressing  of  sterile  cotton  and  a  light  bandage  which  pro- 
tects it  from  breaking  and  aids,  by  elastic  pressure,  in  the 
process  of  absorption.  Where  it  is  desirable  to  keep  up 
the  counterirritation,  the  cuticle  of  the  blister  is  cut  en- 
tirely away  arid  the  surface  dressed  with  savin  ointment, 
an  ointment  made  from  the  volatile  oil  found  in  the  tops 
of  the  Juniperus  sabina,  intensely  irritating,  especially  to 
the  denuded  surface.  This  dressing  should  be  exactly 
the  size  of  the  denuded  surface,  covered  with  an  overlap- 
ping piece  of  gauze. 

On  account  of  the  physical  effect  of  the  drug  the  condi- 
tion of  the  kidneys  must  be  carefully  watched  when  blister- 
ing is  used  in  the  treatment  of  a  patient. 

In  conditions  where  effusion  is  extensive  it  is  frequently 
desirable  to  apply  the  treatment  over  a  greater  length  of 
time.  In  these  cases  a  flying  blister  is  ordered.  A  space 
is  mapped  out,  divided  into  four  or  six  two-inch  squares, 
to  each  of  which,  on  successive  days,  a  blister  is  applied. 
After  the  last  space  is  blistered  the  first  space  is  usually 
ready  for  a  second  application,  if  still  necessary,  or  a  fresh 
square  may  be  begun  beside  the  first. 

A  mixture  of  guaiacol  and  glycerin  is  sometimes  used  as 
a  vesicant,  applied  and  treated  in  the  same  way  as  canthar- 
idal  collodion. 

Ammonia  (aqua]  or  chloroform  can  be  used  as  vesi- 
cants where  cantharides  is  unattainable.  They  may  be 
applied  by  saturating  a  piece  of  gauze  the  necessary  size 
with  one  or  the  other;  the  gauze  is  then  applied  directly 
to  the  surface  and  covered  with  some  protective  and  a 
bandage.  A  group  of  small  vesicles  should  rise  in  from 
ten  to  fifteen  minutes.. 

Blistering  may  be  also  accomplished  by  pouring  a  few 


152  LOCAL   APPLICATIONS 

drops  of  ammonia  water  (aqua  fortis)  directly  on  the  skin, 
excluding  the  air  by  holding  a  watch-glass  over  the  appli- 
cation until  the  vesicles  rise.  Kerosene  oil  may  also  be 
employed  with  equal  parts  of  sweet  oil.  It  is  applied  on 
gauze  and  covered  with  some  protective. 

Pustulants. — Croton  oil  (oleum  tiglii)  is  a  powerful 
vesicant,  producing,  instead  of  a  blister  of  clear  serum,  a 
collection  of  small  vesicles  which  quickly  become  pustulous. 
Tartar  emetic  applied  to  the  skin  has  the  same  effect. 
Croton  oil  may  be  mixed  with  equal  parts  of  olive  oil 
and  applied  on  muslin  or  gauze,  covering  the  application 
with  some  protective;  more  commonly,  a  piece  of  flannel  or 
absorbent  cotton  is  soaked  with  a  small  amount  and  rubbed 
briskly  over  the  skin  until  the  surface  is  well  reddened. 
The  pustules  should  appear  about  four  hours  after  the 
application.  If  there  is  no  result,  the  process  is  repeated. 

ESCHAROTICS 

Certain  drugs  brought  in  contact  with  the  skin  destroy 
the  soft  tissues  and  cause  sloughing.  They  are  termed 
caustics  or  escharotics.  While  not  applied  as  remedial 
agents  to  healthy  tissue,  drugs  with  this  property  should 
be  known  and  recognized  in  order  to  avoid  accidents. 

The  following  list  may  be  memorized: 

Acids  (undiluted) — carbolic,  chromic,  nitric,  acetic, 
sulphuric,  arsenous;  caustic  potash,  caustic  soda;  copper 
sulphate,  silver  nitrate,  mercuric  nitrate,  zinc  chlorid, 
antimony  chlorid,  bromin,  lime. 

LINIMENTS 

It  must  not  be  overlooked  that  friction  with  the  open 
palm  of  the  hand  is,  in  many  instances,  one  of  the  most 
valuable  forms  of  mild  counterirritant.  Its  efficacy  is 
increased  if  oil  or  alcohol  is  used.  Frequently  the  oil 
or  alcohol  is  made  the  vehicle  of  a  drug  with  anodyne  or 
stimulating  properties,  forming  what  is  known  as  a  lini- 
ment. A  sufficient  quantity  of  the  liniment  is  taken  on 
the  palm  and  rubbed  into  the  skin  over  the  affected  area. 
The  application  is  specially  employed  for  affected  joints  in 


PLASTERS  153 

conditions  of  subacute  and  chronic  rheumatism,  and  is 
applied  to  the  chest  in  chronic  bronchitis.  The  medic- 
inal substances  most  commonly  incorporated  in  liniments 
are  opium,  aconite,  belladonna,  ammonia,  hartshorn,  arnica, 
chloroform,  camphor,  mustard,  and  turpentine.  The  soap 
liniment  so  frequently  employed  contains  alcohol,  opium, 
camphor,  and  tincture  of  green  soap. 

Friction  should  be  given  with  the  whole  hand  flat,  and 
should,  generally  speaking,  follow  the  direction  of  the 
lymphatic  circulation,  i.  e.,  from  the  extremities  toward 
the  heart. 

PLASTERS 

Local  application  to  the  unbroken  surface  is  also  made  in 
the  form  of  a  plaster,  or  emplastrum.  The  remedial  agent 
is  mixed  with  an  adhesive  substance  such  as  resin  (pitch), 
which  melts  at  the  temperature  of  the  body,  and  with 
rubber.  The  preparation  is  spread  on  kid  or  swansdown 
and  applied  directly  to  the  skin  surface,  where  it  ad- 
heres, as  a  rule,  without  other  support.  If  kid  is  used,  it 
should  be  freely  perforated.  Drugs  with  counterirritant, 
anodyne,  astringent,  and  other  properties  are  frequently 
applied  by  this  means.  The  most  commonly  employed 
plasters  are  the  following,  all  of  which  are  official  prepara- 
tions : 

Mustard-leaf  \     ^   , 

Cantharides  plaster  }seeabove' 

Capsicum  plaster,  employed  as  a  counterirritant  to  lelieve  mus- 
cular pain. 

Mercury  plaster  (30  per  cent,  mercury)  or — 

Mercury  and  ammonia  plaster  (18  per  cent,  of  mercury),  used 
where,  besides  the  counterirritant  property,  the  action  of  mer- 
cury on  the  system  is  desired. 

Asafetida  plaster  combines  the  properties  of  counterirritant  and 
antispasmodic.  It  is  used  to  some  extent  to  relieve  gastric  and 
intestinal  distent  ion. 

Diachylon  or  lead  plaster  contains  acetate  of  lead,  soap,  and  water. 

Soap  plaster,  a  milder  form  of  the  lead  plaster;  both  are  mildly 
astringent  applications  used  chiefly  in  surgery. 

Belladonna  plaster,  employed  for  anodyne  purposes  and  for  the 
property  possessed  by  belladonna  of  drying  up  secretions;  fre- 
quently applied  to  the  breasts  in  order  to  dry  up  milk,  or  to 
enlarged  painful  glands.  Applied  locally  to  the  muscles  it  re- 
lieves pain,  such  as  lumbago,  and  affords  comforting  support. 

Opium  plaster,  applied  for  anodyne  purposes,  but  less  generally 
than  the  belladonna  plaster. 


154  LOCAL   APPLICATIONS 

The  adhesive  plaster  in  general  use  is  made  of  rubber, 
petroleum,  and  either  lead  acetate  or  zinc  oxid.  The 
astringent  property  is  very  slight.  Adhesive  plaster  is 
used  chiefly  for  support,  to  exert  pressure,  and  in  the  ap- 
plication of  splints  and  other  external  appliances  (Chap. 
VIII). 

In  applying  a  plaster  care  must  be  taken  that  it  fits  the 
surface  smoothly  without  wrinkles.  Snipping  the  margin 
freely  will  generally  accomplish  this  result. 

A  plaster  applied  to  the  breast  should  be  cut  circular 
and  a  hole  made  in  the  center  to  avoid  covering  the  nipple. 
Most  usually  this  is  the  belladonna  plaster  used  to  dry  up 
the  secretion  of  milk. 

A  plaster  is  left  on  until  the  result  for  which  it  was 
applied  is  attained.  An  anodyne  plaster  (belladonna, 
opium)  may  be  retained  as  long  as  it  is  comfortable  unless 
there  are  symptoms  of  too  free  absorption  of  the  drug. 
(See  Poisons.)  In  removing,  if  a  plaster  does  not  come 
away  readily,  a  little  turpentine  or  chloroform  will  dissolve 
the  adhesive  substance,  when  the  plaster  can  be  removed 
without  pain.  If  a  mustard,  capsicum,  or  cantharides 
plaster  sticks,  it  should  be  moistened  with  sweet  oil. 
Most  plasters  adhere  more  readily  and  are  more  comfort- 
able if  slightly  warmed  before  applying.  The  skin  should 
be  previously  washed  with  soap  and  water  and  dried. 

Antiphlogistine  is  a  patent  preparation  (formula  un- 
published) of  medicinal  substances  and  a  natural  Denver 
mud,  which  possesses  the  property  of  relieving  pain  and 
reducing  inflammation.  It  is  spread  thickly  on  stout 
material,  cotton  or  linen,  and  applied  directly  to  the  skin 
surface.  Unless  warmed  before  applying,  it  has  a  dis- 
agreeable, clammy  feeling.  It  may  be  left  on  for  from  six 
to  twenty-four  hours,  after  which  it  becomes  dry  and 
uncomfortable.  Should  some  of  the  preparation  adhere  to 
the  surface  after  the  plaster  is  removed,  it  may  be  washed 
off  with  soap  and  water.  At  the  present  day  its  use  has 
a  certain  vogue,  especially  in  the  treatment  of  subacute 
inflammations. 


CHAPTER  IV 

ENEMATA,  ENTEROCLYSIS,  CONTINUOUS  RECTAL 
INFUSION,  SUPPOSITORIES,  DOUCHES,  TAM- 
PONS, CATHETERIZATION,  LAVAGE,  GAVAGE, 
NASAL  FEEDING 

Simple,  Purgative,  Nutritive,  Medicated  Enemata — Supposi- 
tories— Douches,  Vaginal,  Intra-uterine — Vaginal  Tampon — Vaginal 
Packing — Nasal,  Ear,  and  Eye  Douches — Catheterization — Bladder 
Irrigation — Guarded  Catheter— The  Male  Catheter — Lavage — 
Gavage. 

ENEMATA 

AN  enema,  or  clyster,  is  a  fluid  injected  into  the  lower 
bowel  by  way  of  the  rectum.  It  is  employed  to  relieve 
constipation,  to  check  diarrhea,  as  a  vehicle  for  the  ad- 
ministration of  food,  water,  medicine,  or  stimulation  to 
the  general  system,  and  as  a  local  application.  More 
rarely  it  is  used  as  a  means  of  reducing  temperature. 

The  rectum,  it  will  be  remembered,  is  the  lowest  division 
of  the  large  intestine;  the  opening  is  known  as  the  anus, 
and  is  guarded  by  a  sphincter  or  ring  muscle  called  the 
sphincter  ani.  It  is  a  straight  passage,  occupying  the 
posterior  portion  of  the  pelvic  cavity,  and  running  in  a 
direction  from  the  anus  backward  and  toward  the  left  of 
the  abdomen.  About  eight  inches  above  the  anus  the 
rectum  is  connected  with  the  descending  branch  of  the 
colon,  or  large  intestine,  by  an  S-like  curve,  called  the 
sigmoid  flexure,  which  passes  over  the  bony  brim  of  the 
pelvis  into  the  abdominal  cavity. 

The  walls  of  the  large  intestine  contain  no  secreting 
glands  for  the  digestion  of  food;  in  common,  however, 
with  all  other  portions  of  the  intestinal  tract,  they  have  the 
power  of  absorption.  Food,  water,  medicine,  etc.,  in- 
troduced into  the  large  intestine  become  absorbed  and 
distributed  over  the  general  system  in  the  same  manner 

155 


156 


ENEMATA,    ETC. 


as  when  absorbed  through  the  small  intestine.  Poison- 
ous products  present  in  the  colon,  as,  for  example, 
those  formed  by  decomposing  food-particles,  are  also 
readily  absorbed,  and  produce  symptoms  of  general 
systemic  toxemia,  the  earliest  manifestations  of  which  are 
the  headache,  malaise,  and  nervous  irritability  which 
accompany  constipation.  To  keep  the  intestines  free  of 
such  accumulation  is  a  first  necessity  if  health  is  to  be 
preserved,  and  to  aid  in  so  doing  is  the  most  common 
use  of  the  enema. 

The  enema  is  best  administered  by  a  tube  of  soft  rubber 
sufficiently  thick  to  be  non-collapsible. 

Special  tubes  of  various  sizes  are  sold  for  this  purpose, 
known  as  rectal  tubes.  If  a  very  small  size  is  necessary, 
a  large-sized  "soft"  catheter  is  used,  while  for  colonic 
flushing  a  stomach-tube  may  be  required. 


Fig.  26. — Rectal  tube  with  funnel  for  nutritive  or  medicated  enemata. 

The  best  rectal  tube  for  most  purposes  has  the  end  of 
solid  rubber,  cone-shaped,  and  the  opening  on  the  side 
about  an  inch  from  the  tip.  When  the  opening  is  directly 
at  the  end,  the  opening  more  readily  becomes  blocked 
with  the  contents  of  the  rectum. 

The  rectal  tube  may  be  connected  with  the  tubing  of  a 
douche-can  or  "  fountain  "  bag  by  a  short  glass  connect- 
ing tube,  and  where  a  considerable  quantity  of  fluid  is 
to  be  ejected,  the  bag  or  can  is  usually  used.  It  should 
be  hung  from  two  to  three  feet  higher  than  the  patient. 
For  the  simple  enema  to  relieve  constipation  the  hard- 
rubber  nozzle  sold  with  the  fountain  syringe  bag  may  be 
used  instead  of  the  rectal  tube. 

For  small  enemata,  especially  those  containing  drugs, 
when  it  is  of  importance  that  the  entire  enema  should 


EN  EM  ATA  157 

roach  the  bowel,  the  long  tubing  has  obvious  disadvantages. 
In  these  cases  a  funnel  is  attached  to  the  end  of  the  rectal 
tube  and  the  enema  poured  into  it  from  a  pitcher.  The 
barrel  of  a  large-sized  glass  syringe  makes  the  best  funnel 
for  the  purpose  (Fig.  26) ;  its  capacity  is  known  accurately, 
and  its  shape  lessens  the  risk  of  spilling.  For  very  small 
medicated  enemata  the  tube  should  not  be  more  than 
eight  inches  long,  and  some  prefer  to  use,  for  this  pur- 
pose, the  ball  syringe. 

The  ball  syringe  is  simply  a  hollow  ball 
of  soft  rubber,  to  which  is  attached  a 
short,  hard-rubber  rectal  nozzle.  The 
fluid  is  drawn  into  the  ball  by  expressing 
the  air  and  allowing  the  ball  gradually 
to  expand,  while  the  nozzle  is  held  below 
the  surface  level  of  the  fluid.  When  filled, 
superfluous  air  must  be  expressed  by 
holding  the  ball  with  nozzle  directly  up- 
right and  pressing  gently  until  the  fluid 
appears  at  the  end.  The  pressure  must  Fig .27—  Ball 
not  be  relaxed  or  air  will  be  sucked  into  syringe, 

the  vacuum. 

In  giving  an  enema,  care  must  be  exercised  to  avoid 
injecting  air  into  the  bowel,  which  causes  cramping  pains 
and  may  produce  distention  difficult  to  relieve.  To  pre- 
vent this  the  tube  must  be  filled  with  fluid  first,  and  either 
clamped  or  pinched  between  the  finger  and  thumb  to 
retain  the  fluid  while  inserting  the  tube.  For  the  same 
reason,  where  the  funnel  is  used,  it  must  be  replenished 
from  the  pitcher  always  before  it  has  become  empty. 
If  these  details  are  not  attended  to,  the  air  already  in  the 
tube  is  directly  forced  into  the  bowel  by  the  moTe  solid 
column  of  water  behind  it;  where  a  douche-can  or  bag  is 
used,  a  considerable  quantity  may  be  thus  injected. 

A  second  point  to  be  borne  in  mind  is  that  the  first 
flow  of  fluid  will  be  chilled  by  running  through  the  tube 
and  should  be  run  off  before  the  rectal  tube  or  nozzle  is 
inserted  if  the  enema  is  to  be  given  warm  or  hot.  Where 
the  enema  is  a  measured  quantity  to  be  retained,  the 
portion  run  off  must  be  returned  to  the  bulk  of  the  enema. 


158  ENEMATA,    ETC. 

The  temperature  may,  where  practical,  be  tested  by 
running  the  fluid  over  the  back  of  the  hand. 

The  above  details  are  equally  important  wherever  fluid 
is  injected  into  the  body,  either  by  douche,  etc.,  into  the 
cavities,  or  subcutaneously  into  the  tissues.  (There  is 
one  exception,  the  injection  of  food  into  the  stomach 
either  by  the  stomach  or  nasal  tube.  See  below.)  The 
passage  of  the  tube  is  made  easier  by  lubricating  the  end 
well  with  soapy  water.  If  the  mucous  membrane  is 
delicate,  as  in  young  children,  sterile  oil  or  vaselin  may 
be  used  and  the  anus  should  also  be  lubricated.  There 
is  a  prejudice  against  using  oil  or  vaselin  unnecessarily; 
principally  because  they  afford  too  good  a  medium  for  the 
development  of  bacteria,  but  also  because  all  oils  have  a 
destructive  effect  on  rubber. 

In  giving  an  enema  the  patient  should  be  on  the  left 
side,  toward  which  the  rectum  is  directed,  or  flat  on  the 
back;  in  either  case  with  the  knees  flexed  in  order  to 
relax  the  abdominal  muscles.  For  special  purposes  the 
knee-chest  position  is  ordered.  (See  Positions,  p.  231.) 
In  many  cases  it  is  necessary  to  have  the  pelvis  elevated 
higher  than  the  natural  position  of  the  body;  either  the 
pelvis  may  be  raised  on  pillows,  or  the  lower  end  of  the 
bed  may  be  elevated  on  blocks.  Under  the  patient  is 
placed  a  small  rubber  sheet  covered  with  a  draw-sheet 
or  thick  towel;  the  night-dress  is  rolled  up  out  of  the  way, 
and  a  single  blanket  or  sheet  is  used  as  a  covering.  The 
enema  may  be  given  entirely  under  cover;  where  this  is 
considered  undesirable,  the  covering  can  very  easily  be 
arranged  so  that  only  the  anus  is  exposed.  The  bed-pan 
or  commode  should  be  at  hand  before  the  injection  is 
begun. 

The  tube  inserted,  it  should  be  pushed  gently  in  one 
direction  upward,  backward,  and  toward  the  left,  using 
no  force.  If  resistance  is  felt  from  the  contents  of  the 
rectum,  some  fluid  should  be  run  in  through  the  tube; 
this  will  dilate  the  rectum  and  make  room  for  the  tube  to 
pass  up  beside  the  impaction.  Resistance  should  not  be 
overcome  by  moving  the  tube  or  nozzle  about;  this  irri- 
tates and  may  injure  the  mucous  membrane,  causes  pain, 


ENEMATA  159 

and  generally  leads  to  blocking  the  eye  of  the  tube  with 
foces.  If,  after  insertion,  the  fluid  does  not  run,  the  eye 
has  become  blocked.  The  tube  must  be  withdrawn  and 
water  run  through  the  tube  until  the  impaction  is  washed 
out,  after  which  it  can  be  again  inserted. 

Instances  occur  where  the  rectum  is  so  packed  with 
hard,  dry  feces  that  it  is  impossible  to  pass  the  tube.  In 
these  cases  it  becomes  necessary  to  unload  the  rectum 
first  with  the  finger,  carefully  protected  by  a  glove  or 
rubber  finger-stall,  and  freely  lubricated.  The  finger 
should  not  be  inserted  unless  thus  protected,  and  this  not 
only  from  principles  of  cleanliness,  but  because  the  finger- 
nail may  easily  scratch  the  delicate  mucous  membrane. 

Peristalsis1  is  frequently  excited  on  first  beginning  an 
enema,  leading  the  patient  to  imagine  he  cannot  retain  it. 
If  this  occurs,  by  pinching  the  tube  the  enema  can  be 
stopped  until  the  desire  to  expel  it  has  passed,  when  it 
can  be  continued.  By  proceeding  slowly  and  frequently 
pausing,  a  much  larger  quantity  can  be  retained  than  if 
the  enema  is  injected  rapidly  and  with  force  into  the 
rectum. 

On  finishing,  the  tube  is  slowly  and  gently  withdrawn, 
pinching  it  between  the  fingers  to  avoid  spilling  any  fluid 
remaining.  If  it  is  desired  to  retain  the  enema,  a  folded 
towel  is  held  for  a  few  moments  in  such  a  manner  that  the 
buttocks  are  pressed  together  over  the  anus. 

An  enema  is  prescribed  to  be  given  either  low  or  high, 
terms  which  signify  which  part  of  the  colon  it  is  desired 
to  reach.  In  giving  a  low  enema  the  tube  is  passed  only 
into  the  rectum,  a  distance,  that  is,  of  from  four  to  eight 
inches.  In  giving  a  high  enema  the  object  is  to  reach  as 
far  up  the  colon  as  possible,  and  the  tube  must  be  passed 
beyond  the  sigmoid  flexure,  more  than  eight  inches. 
To  do  so  requires  patience  and  skill;  the  curve  must  be 
passed  by  gentle  manipulation,  and  force  on  no  account 
used.  Frequently  the  tube  appears  to  slip  easily  into  place, 

1  Peristalsis  is  the  rhythmic,  wave-like  contraction  of  the  muscu- 
lar walls  of  the  stomach  and  intestines  by  which  food  is  propelled 
forward  in  the  direction  of  the  anus.  It  is  excited  by  the  presence 
of  food,  etc.,  in  the  stomach  and  intestines. 


160  .ENEMATA,    ETC. 

but  if  an  examining  finger  is  passed  into  the  rectum,  it 
will  be  found  to  have  coiled  back  on  itself  and  to  be  lying 
entirely  in  the  rectum.  Sometimes  a  tube  of  large  caliber 
is  more  easily  passed  than  a  small  one.  Once  past  the 
sigmoid  flexure,  the  tube  should  be  pushed  forward  as 
long  as  it  meets  no  resistance.  When  resistance  is  met, 
the  tube  is  withdrawn  an  inch  or  two  and  the  enema 
started. 

The  simple  enemata  for  relieving  temporary  constipa- 
tion, and  those  employed  as  a  local  application,  are  given 
low;  practically  all  other  enemata  should  be  given  high. 

The  temperature  of  an  enema  varies  with  the  results  to 
be  attained.  A  purgative  enema  is  given  hot — from  100° 
to  105°  F.;  a  stimulating  enema,  from  105°  to  110°  F.;  an 
enema  for  the  arrest  of  local  hemorrhage,  110°  to  120°  F.; 
an  enema  for  nutritive  purposes  should  be  about  the  normal 
temperature  of  the  body;  a  bland  enema  is  usually  given 
cool,  that  is,  the  chill  just  off,  while  for  special  purposes, 
such  as  the  reduction  of  the  temperature  of  the  body  or 
the  arrest  of  local  hemorrhage,  and  in  the  treatment  of 
acute  dysentery  or  cholera,  an  enema  may  be  ordered  cold 
or  even  iced.  In  the  majority  of  cases  an  enema  which  is 
the  vehicle  for  a  drug  is  given  cold  or  cool,  in  order  not 
to  risk  altering  the  active  properties  of  the  drug  by  heat : 
to  this  rule  the  medicated  purgative  enema  is  an  exception. 

The  quantity  given  by  enema  also  varies  greatly.  The 
common  purgative  enema  is  usually  from  two  to  four 
pints  for  an  adult,  from  one  to  two  pints  for  a  child,  and 
half  a  pint  for  an  infant.  When  given  in  order  to  empty 
the  bowel  before  an  operation,  the  enema  is  repeated  until 
it  returns  clear.  If  it  is  desired  to  retain  the  enema,  the 
quantity  is  small,  anything  above  six  ounces  being  liable 
to  be  rejected  or  to  excite  peristalsis,  which  may  cause  the 
whole  to  be  returned. 

In  the  care  of  an  infant  the  giving  of  an  enema  may  be 
a  frequent  duty,  and  is  one  which  requires  to  be  performed 
with  the  greatest  care  and  attention  to  details.  A  small- 
sized  rubber  catheter  is  used,  attached  either  to  the  glass 
funnel  or  to  the  douche-bag.  The  infant  is  laid  com- 
fortably on  its  left  side  on  the  lap,  on  which  is  a  small 


ENEMATA  161 

blanket  covered  by  a  rubber  sheet,  both  warmed;  the  cloth- 
ing is  rolled  up  out  of  the  way,  and  a  warm  diaper  placed 
under  the  buttocks.  The  legs  are  flexed  and  the  baby 
held  by  the  feet.  The  anus,  the  adjacent  parts,  and  the 
tube  are  carefully  lubricated  with  sterile  vaselin  or  cold 
cream.  The  enema  is  then  given  in  the  usual  way.  If 
the  tube  and  funnel  are  used,  the  nurse  will  require  an 
assistant  to  help  her;  if  the  bag  or  can  is  used,  it  should  be 
hung  about  a  foot  higher  than  the  lap,  and  the  tube  ap- 
propriately shortened.  The  injection  over,  a  suitable 
vessel  is  placed  under  the  buttocks,  and  the  baby,  covered 
with  a  warm  blanket,  is  held  on  the  lap  until  the  enema  has 
acted.  Owing  to  the  smallness  of  the  limbs  a  large  pro- 
portion of  the  baby's  body  is  necessarily  exposed  during 
the  process.  Care  should,  therefore,  be  taken  that  the 
proceeding  takes  place  in  a  well-warmed  place,  free  of 
drafts,  preferably  by  an  open  fire,  and  that  all  that  comes 
in  contact  with  the  baby  is  well  warmed.  No  baby  can 
afford  to  run  the  risk  of  sudden  chilling  of  the  surface  of  its 
body. 

The  following  are  the  more  commonly  ordered  enemata; 
the  quantities  given  are  those  for  an  adult. 

Simple  Enema. — Plain  hot  water  may  be  used  as  an 
enema  to  relieve  mild  constipation  or  to  empty  the  rectum 
before  rectal  feeding.  It  is  sometimes  ordered  for  invalids 
who  imagine  that  the  soap-suds  enema  causes  griping. 
Quantity,  two  to  four  pints;  temperature,  100°  to  105°  F. 

Soap-suds  Enema. — Hot  water  is  made  soapy  with 
Castile  or  any  pure  soap.  No  soaps  containing  much  soda, 
such  as  scrubbing  or  laundry  soap,  should  be  used,  as  they 
are  irritating  to  the  mucous  membrane.  The  frothy 
suds  which  contain  air-bubbles  should  not  be  injected, 
as  they  will  cause  unnecessary  griping.  The  soap-suds 
enema  is  universally  used  to  induce  an  action  of  the 
bowels.  Quantity,  two  to  four  pints;  temperature,  100° 
to  105°  F. 

Normal  Salt  Solution  Enema. — To  two  pints  of  water 

are   added  two  and  one-quarter  teaspoons  of  common 

table-salt  (TV  of  1  per  cent.).     The  normal  salt  solution 

enema  is  used  for  various  purposes:  to  irrigate  the  lower 

11 


102  ENEMATA,    ETC. 

bowel  in  conditions  of  chronic  enterocolitis,  to  cleanse 
the  bowel  before  rectal  feeding,  for  the  destruction  of 
intestinal  worms,  for  the  relief  of  thirst,  especially  follow- 
ing an  operation  or  severe  hemorrhage,  and  as  a  means 
of  stimulating  the  system  in  conditions  of  collapse;  usual 
temperature,  110°  to  105°  F.;  as  a  general  stimulant,  110° 
to  120°  F. 

Nutritive  Enema. — Nutritive  enemata  may  be  composed 
of  any  concentrated  food  substance  in  liquid  form.  They 
commonly  contain  peptonized  milk,  egg,  some  concentrated 
protein,  such  as  a  beef  essence,  beef-juice,  peptones,  or 
liquid  peptonoids.  As  absorption  only,  and  not  digestion, 
is  carried  on  in  the  large  intestine,  the  food  used  is  first 
partially  digested  or  peptonized,  unless  already  in  the  form 
of  peptones  or  albuminoids,  which  are  ready  for  absorption 
without  being  subjected  to  the  action  of  digestive  secretions. 

A  common  formula  for  a  nutritive  enema  is  as  follows: 

Peptonized  milk,  3  ounces. 
Beef-juice,  2  drams. 
White  of  one  egg. 
Salt,  half  a  level  teaspoon. 

The  beef -juice  may  be  omitted  altogether  or  bouillon 
(2  ounces),  liquid  peptonoids  (half  an  ounce),  beef  pep- 
tones, or  some  beef-extract  (1  to  2  drams)  may  be  used 
in  its  place.  Half  an  entire  egg  is  sometimes  preferred  to 
the  white  only,  or  the  egg  may  be  omitted  and  a  larger 
quantity  of  beef-juice  used. 

(To  peptonize  milk  see  Appendix.) 

In  preparing  the  enema  the  milk  is  warmed  in  a  double 
boiler  to  the  required  temperature  (95°  F.),  and  the  salt 
and  beef-juice  added  when  ready.  The  egg-albumen 
is  broken  in  a  cup  with  a  spoon  and  added  last,  slowly, 
stirring  all  the  time. 

If  stimulants  or  medicines  are  to  be  given  in  the  enema, 
they  are  added  immediately  before  administration  and 
not  subjected  to  the  process  of  predigestion.  Stimulants 
— whisky  or  brandy — must  be  added  slowly,  stirring  all 
the  time  to  prevent  curdling.  Medicines  should  be  given 
with  the  first  quantity  injected,  so  that  nothing  may  be 
lost  in  the  tube. 


EN  EM  AT  A — NUTRITIVE    ENEMATA  163 

A  nutritive  enema  should  not  exceed  from  four  to 
six  ounces,  a  larger  quantity  being  liable  to  be  rejected, 
and  should  be  given  high;  it  should  be  about  the  consist- 
ence of  thick  cream.  If  not  sufficiently  thick,  a  little 
cooked  starch  or  flour  may  be  added.  To  insure  reten- 
tion it  must  be  given  very  slowly,  almost  drop  by  drop, 
regulating  the  speed  by  pinching  or  clamping  the  tube. 
The  pelvis  should  be  raised  higher  than  the  shoulders 
during  the  process.  The  enema  is  usually  given  at 
intervals  of  four,  six,  or  eight  hours,  according  to  cir- 
cumstances. 

The  nutritive  enema,  or  rectal  feeding,  is  ordered  in 
cases  where,  from  any  cause,  the  patient  cannot  be  fed 
through  the  stomach.  Such  a  condition  may  be  the  re- 
sult of  gastric  ulcer,  cancer  of  the  stomach,  stricture  of 
the  esophagus,  persistent  vomiting,  and  similar  causes. 
Rectal  feeding  may  be  the  only  means  of  nourishment  for 
weeks  at  a  time.  In  these  cases  it  is  important  to  keep 
the  bowel  free  from  accumulations  of  food-particles,  which, 
when  not  absorbed,  must  decompose,  and,  as  a  consequence, 
set  up  diarrhea,  which  will  render  rectal  feeding  impossible. 
To  prevent  this,  the  bowel  is  cleansed  at  least  once  a  day 
by  a  simple  enema,  or,  if  preferred,  by  an  enema  of  soap- 
suds or  salt  solution.  Some  doctors  order  a  small  (half 
a  pint)  simple  enema  half  an  hour  before  each  feeding, 
but  such  frequent  passing  of  the  tube  is  liable  to  irritate 
the  mucous  membrane.  After  the  enema  is  given,  the 
patient  should  lie  quite  still  for  half  an  hour. 

Stimulating  Enemata. — No.  1:  The  normal  salt  solu- 
tion enema,  given  at  a  temperature  of  110°  to  120°  F.,  is 
a  valuable  general  stimulant  in  conditions  of  shock,  low- 
ered vitality,  or  collapse.  It  should  be  injected  as  high 
as  possible  into  the  colon,  and  not  more  than  one  pint 
given  at  a  time  to  favor  retention. 

No.  2:  Strong  black  coffee,  four  to  six  ounces,  to  which 
may  be  added  brandy  or  whisky,  one  to  two  ounces.  It 
is  also  given  high,  at  a  temperature  of  105°  to  110°  F. 
To  make  a  coffee  enema  quickly  tie  a  cupful  of  ground 
coffee  loosely  in  a  piece  of  muslin,  place  in  the  coffee-pot, 
and  pour  on  two  cups  of  boiling  water;  cover  and  set  on 


164  ENEMATA,    ETC. 

the   stove   three   minutes,    then   strain.     Less   coffee   is 
necessary  if  more  time  is  available. 

No.  3:  Brandy  or  whisky  (one  to  two  ounces)  is  fre- 
quently ordered  as  an  emergency  stimulating  enema. 
They  are  usually  given  diluted  with  hot  normal  salt 
solution;  hot  milk,  hot  tea,  or  hot  coffee  is  also  often  used 
as  a  vehicle.  The  total  quantity  should  not  be  more  than 
six  ounces.  If  the  stimulant  is  to  be  frequently  repeated, 
it  is  best  given  in  four  ounces  of  cooked  starch,  to  lessen 
the  irritating  effects  of  alcohol  on  the  mucous  mem- 
brane. 

Medicated  Enemata. — Drugs  or  medicinal  preparations 
may  be  given  by  enema  either  for  local  action  or  for  general 
systemic  effect.  When  for  the  latter  use,  a  larger  dose 
is  given  than  when  the  drug  is  administered  by  the  mouth 
or  by  subcutaneous  injection.  In  the  majority  of  in- 
stances the  dose  by  rectum  is  twice  that  given  by  mouth. 
Medicated  enemata  are  given  high,  unless  for  local  action 
only. 

Oil  Enema. — From  six  ounces  to  a  pint  of  olive  oil  is 
warmed  to  a  temperature  of  about  90°  F.,  and  given  very 
slowly  as  a  high  enema.  In  from  two  to  six  hours  it  is 
followed  by  a  suds  enema. 

The  oil  enema  is  given  to  soften  hard  masses  of  feces, 
and  is  frequently  ordered  before  the  first  bowel  movement 
after  rectal  operations. 

The  tube  used  must  be  immediately  cleaned,  as  oil 
quickly  destroys  rubber. 

Glycerin  Enema.— Glycerin,  \  ounce,  diluted  with  an 
equal  quantity  of  warm  water,  is  frequently  used  for  the 
relief  of  chronic  constipation  affecting  the  lower  bowel. 
It  is  most  conveniently  given  with  a  special  glass  syringe 
fitted  with  a  hard-rubber  nozzle  slightly  curved,  and  about 
four  inches  long. 

Medicated  purgative  enemata  are  used  in  cases  of 
obstinate  constipation.  Salts,  either  Rochelle  or  magne- 
sium sulphate,  or  castor  oil  are  used  for  this  purpose. 

Salts  Enema. — To  from  4  to  6  ounces  of  Rochelle 
salts,  or  from  2  to  4  of  sulphate  of  magnesia,  add  suffi- 
cient hot  water  to  make  a  saturated  solution.  The  enema 


MEDICATED    ENEMATA  165 

is  given  at  bedtime  and  followed  in  the  morning  by  a 
suds  enema. 

Castor-oil  Enema. — Make  an  emulsion  of  castor  oil  by 
adding  to  the  quantity  ordered  an  equal  quantity  of  hot 
milk  or  hot  strong  coffee,  and  shaking  well  together  in  a 
corked  medicine  bottle.  Give  slowly,  like  a  nutritive  enema, 
and  follow  by  a  suds  enema  in  from  one  to  four  hours. 

Compound  Purgative  Enema. — An  enema  that  has 
excellent  results  in  relieving  post-operative  constipation 
without  giving  an  aperient  by  mouth  consists  of  magne- 
sium sulphate,  1  ounce,  glycerin,  1  ounce,  turpentine,  \ 
ounce,  in  hot  water,  4  ounces. 

Carminative  enemata  are  used  to  dispel  collections  of 
gas  in  the  bowel  and  so  relieve  distention.  Turpentine, 
asafetida,  and  alum  are  the  drugs  most  commonly  used. 

Turpentine  Enema. — First  method:  Beat  with  a  knife 
from  2  drams  to  \  ounce  of  turpentine  into  a  pint  of  a  hot 
suds  enema;  give  in  the  usual  way,  and  follow,  without 
removing  the  tube,  by  another  pint  or  pint  and  a  half  of 
the  suds  enema. 

Second  method:  Add  from  \  ounce  to  1  ounce  of  tur- 
pentine to  4  to  6  ounces  of  warm  olive  oil,  mixing  well 
with  a  knife  or  by  shaking  in  a  corked  medicine  bottle. 
Follow  in  from  half  to  one  hour  with  a  suds  enema. 

Asafetida  Enema. — The  milk  or  emulsion  of  asafetida, 
which  contains  10  grains  of  asafetida  in  each  ounce,  is 
the  preparation  generally  used.  From  1  to  2  ounces  are 
given  in  equal  quantity  of  hot  water  at  a  temperature  of 
100°  to  105°  F.  Other  medical  substances  may  be  com- 
bined in  the  asafetida  enema,  as  in  the  following  formula, 
known  as  the  compound  asafetida  enema:  Milk  of  asa- 
fetida, 3  ounces;  magnesium  sulphate,  1  ounce;  oil  of  tur- 
pentine, 30  minims;  glycerin,  1  ounce.  The  enema  is 
warmed  by  standing  in  hot  water.  It  should  be  given 
high  and  slowly,  and  followed  by  a  suds  enema  in  about 
twenty  minutes  or  half  an  hour. 

Alum  Enema. — Alum,  from  2  drams  to  £  ounce  in  1 
pint  of  hot  water,  is  sometimes  ordered  for  tha  relief  of 
obstinate  and  dangerous  distention.  It  must  be  ubed  with 
caution  on  account  of  the  poisonous  properties  of  the  drug 


166  ENEMATA,   ETC. 

when  taken  in  large  doses.  If  the  enema  is  retained,  it 
should  be  siphoned  off  after  half  an  hour.  To  remove  an 
enema  by  siphoning  the  rectal  tube  is  passed  and  the  free 
end  lowered  over  a  vessel  placed  at  a  lower  level  than  the 
pelvis. 

Gelatin  Enema. — In  cases  of  hemorrhage  from  the 
stomach  or  upper  bowel  or  other  points  where  the  bleeding 
point  cannot  be  reached  gelatin,  which  aids  in  the  clot- 
ting property  of  blood,  is  frequently  given  as  a  rectal 
injection.  The  gelatin  is  dissolved  in  hot  water  until 
sufficiently  thin  to  run  through  a  tube,  and  from  4  to 
6  ounces  at  a  time  given,  generally  every  eight  to  twelve 
hours. 

Astringent  Enema. — Astringent  injections  are  most 
frequently  given  in  the  form  of  rectal  irrigations  or  douches. 
An  exception  is  the  quassia  enema  for  the  destruction  of 
seat-worms.  An  infusion  is  made  from  chips  of  quassia 
wood,  a  tree  native  to  Jamaica,  by  pouring  a  pint  of  boil- 
ing water  over  one  ounce  of  the  chips  (by  weight).  When 
cold,  the  water  is  strained  off  and  injected  cold.  The  bowel 
should  first  be  cleared  by  a  simple  enema.  Half  a  pint  is 
given  at  a  time,  and  the  enema  generally  repeated  daily 
until  all  the  worms  have  been  hatched  out  and  destroyed. 
The  enema  is  retained  half  an  hour,  the  patient  during 
that  period  being  kept  quietly  lying  down.  If  not  re- 
turned naturally,  it  should  then  be  siphoned  off. 

Starch,  Emollient,  or  Bland  Enema. — A  starch  enema 
is  used  to  relieve  local  irritation,  to  check  diarrhea,  and 
as  a  vehicle  for  the  introduction  into  the  rectum  of  drugs 
given  in  small  doses,  as,  for  example,  the  tinctures.  The 
starch  is  cooked  in  the  usual  manner,  by  dissolving  a 
small  quantity  in  cold  water  and  adding  boiling  water 
until  it  is  suffidbntly  thin  to  run  through  the  tube.  When 
it  has  cooledjto  the  normal  bodily  temperature,  it  is  ready 
for  use.  / 

When  a  drug  is  used,  it  is  added,  immediately  before 
the  injection  is  given,  to  about  |  ounce  of  the  starch;  this 
quantity  is  first  injected,  and  followed  immediately  by 
2  ounolf  more  of  starch.  By  this  means  the  risk  of  some 
of  the^arug  being  left  in  the  tube  is  lessened. 


ENTEROCLYSIS  167 

A  starch  enema  containing  from  10  minims  to  1  dram  of 
tincture  of  opium  is  very  commonly  used  to  check  obstin- 
ate diarrhea.  It  soothes  the  local  irritation,  checks  peris- 
talsis, and  allays  pain.  The  poisonous  properties  of 
opium  must  be  borne  in  mind,  and  close  watch  kept  for 
the  premonitory  symptoms  of  an  overdose,  especially  if 
ordered  for  children,  who,  it  cannot  be  too  frequently  em- 
phasized, stand  opium  very  badly.  As  the  starch  does  not 
flow  easily,  this  enema  is  best  given  with  an  ordinary  glass 
or  a  ball  syringe  attached  to  a  short  length  of  a  rectal  tube, 
a  method  that  may  also  be  employed  in  giving  either  an 
oil  or  a  nutritive  enema  that  proves  difficult  to  inject  in 
the  usual  way. 

Other  drugs,  ordered  in  larger  doses,  when  given  by 
rectum,  are  dissolved  in  warm  (not  hot)  water  or  warm 
milk.  The  quantity  of  fluid  should  not  be  more  than 
two  or  three  ounces;  the  drug  is  dissolved  in  half  the 
quantity,  and  that  half  given  first,  the  remainder  follow- 
ing immediately.  Sedatives,  such  as  bromid,  chloral, 
chloralamid,  trional,  etc.,  are  given  in  this  way.  As  in 
administering  narcotics  in  any  form,  the  patient  must  be 
composed  for  sleep  before  a  sedative  enema  is  given. 

ENTEROCLYSIS 

Enteroclysis,  or  intestinal  irrigation,  by  which  is  meant 
the  flushing  out  of  the  lower  bowel  with  a  quantity  of 
fluid,  is  a  form  of  treatment  used  in  many  conditions. 
The  more  important  are  as  follows:  in  the  treatment  of 
intestinal  disorders,  especially  those  associated  with  chronic 
diarrhea  or  chronic  constipation;  for  the  destruction  of 
seat- worms;  as  a  local  application  to  the  mucous  mem- 
brane; as  a  disinfectant  to  the  bowel;  to  restore  fluid 
to  the  body  after  hemorrhage;  as  a  general  stimulant 
in  conditions  of  shock  and  collapse;  and  to  reduce  high 
temperature.  The  irrigation  is  continued  for  a  specified 
time — usually  from  five  to  fifteen  minutes;  in  some  con- 
ditions a  continuous  irrigation  is  ordered  to  be  maintained 
for  many  hours.  The  quantity  ordered  may  vary  from 
a  couple  of  pints  to  several  quarts.  The  greater  portion 


168  ENEMATA,   ETC. 

of  the  fluid  is  returned  at  once,  though  a  certain  amount 
is  necessarily  absorbed. 

The  patient  lies  on  the  back  or  on  the  left  side,  unless 
specially  ordered  in  the  knee-chest  position  (p.  231). 

In  giving  an  enteroclysis  a  second  rectal  tube  is  generally 
used  to  carry  off  the  return  flow.  The  irrigating  tube  is 
connected  to  the  douche-can  or  bag  containing  the  fluid, 
while  the  second  or  return  tube  is  attached  to  a  piece  of 
tubing  sufficiently  long  to  carry  the  fluid  to  a  bucket 
or  convenient  receptacle  placed  lower  than  the  pelvis. 
The  return  tube  is  introduced  only  a  few  inches  up  the 
rectum.  A  bed-pan  or  douche-pan  is  placed  under  the 
patient,  as  some  leakage  of  the  fluid  is  very  apt  to  take 
place  from  the  anus.  If  the  fluid  does  not  return  easily, 
the  return  tube  is  removed  and  the  free  end  of  the  irri- 
gating tube  lowered  over  the  bucket.  In  this  way  the 
contents  are  siphoned  off. 

The  enteroclysis  may  also  be  given  adequately  by  in- 
jecting a  pint  at  a  time  and  siphoning  off  the  amount. 

Special  double  tubes  can  be  obtained  to  be  attached 
to  the  rectal  tube,  and  connected  by  separate  arms  to  the 
irrigating  and  return-flow  tubes.  If  such  a  tube  is  used, 
the  lower  or  return-flow  tube  should  be  clamped  while  the 
fluid  flows  in,  otherwise  there  is  some  risk  that  the  fluid 
may  return  immediately  without  irrigating  the  bowel. 

An  enteroclysis  should  be  given  slowly  and  without 
force.  The  funnel  or  douche-can  should  be  about  two 
feet  above  the  body.  To  assist  in  sending  the  irrigation  as 
high  as  possible,  the  pelvis  should  be  raised  higher  than  the 
shoulders. 

Plain  sterile  water,  normal  salt  solution,  and  either 
astringent  or  bland  solutions  are  used  for  enteroclysis. 

Normal  Salt  Solution. — At  a  temperature  of  100°  to 
105°  F.  enteroclysis  of  normal  salt  solution  is  used  to 
cleanse  and  disinfect  the  bowel  in  many  diseases  of  the 
intestine;  to  restore  fluid  to  the  body  after  severe  hemor- 
rhage; and  to  allay  thirst  after  abdominal  operations: 
given  cold  (70°  to  60°  F.),  it  is  employed  to  reduce 
bodily  temperature,  and  hot  (110°  to  120°  F.),  as  a  general 
bodily  stimulant  in  conditions  of  shock  or  collapse.  In 


ENTEROCLYSIS  169 

these  cases  the  enteroclysis  must  be  given  with  caution, 
and  the  pulse  as  closely  watched  as  when  heat  or  cold 
is  applied  to  the  body  by  any  of  the  methods  described 
in  the  previous  chapter. 

Astringent  Enteroclysis. — -Tannic  acid,  half  a  dram  of 
the  crystals  to  the  pint  of  water,  is  the  most  commonly 
used  astringent  in  the  treatment  of  various  diseases  of  the 
intestines  associated  with  diarrhea,  and  especially  in  the 
treatment  of  infantile  enterocolitis.  In  the  latter  case 
from  1  to  4  pints,  5  to  10  grains  to  the  pint,  is  given  once 
a  day,  care  being  taken  to  siphon  off  the  injection  if  it 
does  not  return  freely.  Nitrate  of  silver  (10  to  20  grains 
to  the  pint — adult)  is  also  ordered  in  cases  of  dysentery. 
The  temperature  usually  ordered  for  an  astringent  entero- 
clysis is  the  normal  bodily  temperature,  but  in  some  cases 
(dysentery,  cholera)  it  is  especially  ordered  cold.  The 
treatment  may  be  ordered  daily  or  two  or  three  times  a 
week. 

Bland  Enteroclysis. — The  bland  enteroclysis  is  ordered 
as  a  local  application  in  chronic  irritated  or  ulcerated  con- 
ditions of  the  intestinal  mucous  membrane,  especially 
of  the  rectum.  Flaxseed  tea,  barley-water,  and  thin 
gruels  are  used,  from  1  to  4  pints  being  given  once  a 
day  or  on  alternate  days,  generally  at  the  normal  bodily 
temperature. 

Flaxseed  Enteroclysis. — Pour  1  quart  of  boiling  water 
over  2  ounces  of  flaxseed  (use  the  seeds  and  not  the  meal), 
stand  in  a  warm  place  until  thickened,  then  cool  to  the 
desired  temperature,  and  strain.  Use  undiluted. 

Barley-water. — Wash  2  ounces  of  pearl  barley  in  cold 
water  until  clean,  and  strain  off  the  water.  Pour  over  the 
barley  2  quarts  of  boiling  water,  simmer  until  reduced  to 
1  quart,  cool  and  strain;  use  undiluted. 

Gruels. — Stir  two  teaspoons  of  oatmeal  flour  in  a  pint 
of  cold  water,  bring  to  the  boil,  and  boil  ten  minutes, 
stirring  all  the  time.  Cool  and  strain;  dilute  if  too  thick 
to  run  through  the  tube. 

The  bland  enteroclysis  may  be  ordered  high  or  low, 
according  to  which  part  it  is  desired  to  subject  to  the 
treatment. 


170  ENEMATA,   ETC. 

A  nurse  may  be  required  to  get  a  patient  ready  for 
colonic  flushing,  often  wrongly  called  abdominal  flushing. 
Normal  salt  solution  at  a  temperature  of  100°  F.  is  gen- 
erally used,  and  the  flushing  given  with  a  small-sized 
stomach-tube,  well  lubricated  and  passed  high  up  the  colon. 
The  patient  is  placed  in  the  knee-chest  position  and 
covered  with  an  examining  sheet  (p.  231).  The  operation 
is  both  a  trying  and  a  tiring  one.  Everything  to  be  re- 
quired should  be  at  hand  before  beginning,  so  that  the 
nurse  is  free  to  give  all  her  attention  to  the  patient. 

CONTINUOUS  RECTAL  INFUSION  OR  SEEPAGE 

A  continuous  flow,  usually  of  hot  normal  salt  solution 
(105°  to  110°  F.),  into  the  rectum  is  at  present  a  frequent 
form  of  treatment  after  some  major  abdominal  operations 
and  in  other  conditions  of  lowered  vitality.  A  douche- 
can  containing  the  fluid  is  attached  to  the  head  of  the  bed, 
a  very  little  higher  than  the  patient's  pelvis.  The  tube 
is  loosely  knotted  or  partially  clamped,  so  that  the  fluid 
flows  drop  by  drop.  The  can  must  be  closely  covered  to 
retain  the  temperature,  and  the  bed  protected  with  a  rub- 
ber sheet  in  case  of  oozing. 

A  special  short  rectal  tube  of  hard  rubber  with  an 
olive-shaped  expansion  at  the  nozzle  is  generally  easily 
kept  in  place.  At  one  hospital  a  large-sized  "  ther- 
mos" bottle  is  ingeniously  used  for  the  purpose  of 
seepage.  The  cork  is  fitted  with  two  pieces  of  glass 
tubing,  to  one  of  which  the  tubing  is  attached,  the  other 
introducing  the  necessary  air  to  cause  the  solution  to 
flow.  The  bottle  is  attached  to  the  railing  at  the  head  of 
the  bed,  a  few  inches  higher  than  the  mattress.  The 
method  is  simple  to  handle,  and  has  the  advantage  of 
keeping  the  solution  at  the  required  temperature.  The 
fixed  position  the  rectal  infusion  entails  makes  it  a  trying 
process  for  the  patient.  Whether  in  the  recumbent  or 
the  upright  position,  every  effort  must  be  employed  to 
make  him  as  comfortable  as  possible  by  a  judicious 
arrangement  of  pillows,  etc. 


SUPPOSITORIES  171 


SUPPOSITORIES 

A  suppository  is  a  solid,  conical  preparation,  about  an 
inch  long,  for  introducing  small  doses  of  drugs,  concen- 
trated foods,  or  local  applications  into  the  rectum,  vagina, 
or,  more  rarely,  the  urethra.  They  are  usually  made  with 
cocoa-butter,  which  melts  at  the  bodily  temperature, 
setting  free  the  drug  contained.  A  rectal  suppository 
should  be  lubricated  with  oil  and  passed  as  far  into  the 
passage  as  the  finger  will  reach,  the  patient  lying  on  the 
left  side.  The  finger  should  be  protected  by  a  finger-cot 
and  also  lubricated.  Drugs  are  administered  in  this  way 
either  for  general  systemic  effect  or  for  local  action. 
Drugs  frequently  given  in  this  way  are  morphin,  opium, 
cocain,  gall,  lead,  tannin,  and  iodoform.  To  keep  them 
from  melting,  suppositories  should  be  kept  on  ice. 

Glycerin  jelly,  in  the  form  of  a  suppository,  is  frequently 
used  as  a  remedy  in  mild  forms  of  constipation  due  to 
muscular  inertia  of  the  lower  bowel,  for  which  purpose  also 
a  suppository  of  white  household  soap  is  effectual.  To 
make  the  latter,  cut  a  splinter  of  soap  and  wash  it  in  hot 
water  until  it  is  smoothly  rounded.  It  may  be  about  three 
inches  long  and  shaped  like  a  pencil. 

An  ice  suppository  may  be  ordered  for  local  hemorrhage 
or  to  relieve  local  inflammation.  A  lump  of  ice  of  suitable 
size  and  shape  is  washed  until  all  sharp  corners  are  rounded 
off,  and  introduced  by  the  finger  into  the  rectum.  In 
treating  local  hemorrhage  the  suppository  is  repeated  at 
short  intervals. 

Suppositories  larger  in  size  are  also  used  for  introduction 
into  the  vagina,  and  are  a  form  of  application  frequently 
used  in  treatment  of  the  cervix  uteri.  In  giving  a  vaginal 
suppository  the  patient  lies  on  her  back  with  the  knees 
flexed;  the  suppository  is  inserted  as  far  as  the  finger  can 
be  introduced.  Smaller  suppositories  are  also  made  for 
urethral  applications,  but  are  not  so  generally  employed. 
They  are  shaped  like  a  fine  pencil  and  are  inserted  only 
as  far  as  they  can  be  pushed,  and  not  followed  up  by  the 
finger. 


172  ENEMATA,    ETC. 

DOUCHES 

A  douche  is  a  local  bath  of  running  water,  and  is  used 
as  a  means  of  applying  treatment  to  the  various  cavities 
of  the  body.  A  douche  may  be  used  to  cleanse  the  cavity 
free  of  discharge,  to  apply  heat  or  cold  to  inflamed  sur- 
faces, to  arrest  local  hemorrhage,  or  to  apply  medicinal 
treatment  to  the  parts.  The  parts  to  which  douching  is 
applicable  are  the  vagina,  uterus,  bladder,  the  nose,  the 
ear,  and  the  conjunctival  cavity  or  sac. 

Vaginal  Douche. — The  vagina  is  a  passage  or  cavity 
situated  between  the  bladder  and  urethra  in  front,  and 
the  rectum  behind,  and  curves  backward,  upward,  and 
finally  slightly  forward.  The  length  of  the  anterior  wall 
is  about  four  inches.  It  terminates  in  a  dome  or  pouch 
from  the  center  of  which  the  cervix  or  neck  of  the  uterus 
hangs  free.  The  walls  of  the  vagina  are  capable  of  enor- 
mous distention.  When  not  distended,  the  mucous  mem- 
branous lining  lies  in  numerous  folds,  which  readily 
form  a  lodging-place  for  secretions  or  discharges. 

In  giving  a  vaginal  douche,  even  for  simple  cleansing 
purposes,  everything  used  should  be  scrupulously  sterile. 
The  special  reason  for  this  is  that  in  many  conditions  the 
cervix  is  slightly  relaxed,  in  which  case  there  is  some  danger 
that  a  portion  of  the  douche  may  be  washed  into  the  cervix, 
and  so  on  into  the  uterine  cavity.  It  will  be  remembered 
that  the  uterine  cavity  has  two  openings  at  the  fundus,  one 
into  each  Fallopian  tube,  the  fine  terminations  of  which 
open  directly  into  the  peritoneal  cavity  and  form  thus  a 
direct  channel  of  communication  from  the  mouth  of  the 
vagina  to  the  peritoneal  cavity,  the  largest  and  most  im- 
portant closed  cavity  of  the  body.  We  remember  that 
these  closed  cavities  present  ideal  conditions  for  the  de- 
velopment of  bacteria,  and  a  douche  carelessly  prepared 
or  administered  may  be  the  means  of  introducing  bacteria 
into  the  peritoneal  cavity,  and  setting  up  septic  peritonitis. 
While  the  percentage  of  such  accidents  is  very  small,  no 
patient  should  be  allowed  to  run  the  most  remote  risk. 

For  the  same  reason,  in  giving  the  vaginal  douche,  no 
force  of  water  should  be  used;  the  can  or  receptacle  for  the 
water  should  not  be  elevated  more  than  two  feet,  and  where 


DOUCHES  173 

infectious  discharges  are  present,  it  should  be  held  just 
sufficiently  high  to  allow  the  water  to  flow. 

The  douche  is  usually  given  from  a  douche-can  of 
enameled  iron,  to  which  is  attached  a  piece  of  tubing  of 
sufficient  length  connected  with  a  vaginal  nozzle.  The 
vaginal  nozzle  is  usually  of  glass,  about  6  to  8  inches  long, 
and  curved  to  follow  the  line  of  the  vagina:  the  end  is 
rounded,  with  perforations  at  the  side,  which  prevents  the 
stream  of  water  being  directed  immediately  on  to  the  cer- 
vix. Can,  tubing,  and  nozzle  are  sterilized,  usually  by 
boiling,  immediately  before  use.  The  patient  is  placed 
in  the  dorsal  position  (p.  229)  on  a  douche-pan,  the  knees 
drawn  up,  and  the  pillows  removed;  she  is  covered  with  a 
single  sheet,  and  the  night-dress  rolled  out  of  the  way. 
In  this  way  she  lies  with  the  pelvis  slightly  elevated.  The 
douche-pan  is  a  flat  receptacle  of  porcelain  or  enameled 
iron,  differing  somewhat  in  shape  from  a  bed-pan,  and  of 
a  larger  capacity:  it  may  be  made  more  comfortable  if  a 
small  pillow  or  folded  towel  is  placed  where  the  back  rests. 

If  there  is  any  discharge,  the  external  parts  should  be 
carefully  cleansed  before  the  douche  is  given,  using  either 
hot  sterile  water  or  boric  solution  (2  per  cent.).  As  in 
the  case  of  a  rectal  injection,  air  must  be  excluded  by 
filling  the  tube  and  nozzle  before  starting  the  douche; 
some  of  the  fluid  also  should  be  run  over  the  back  of  the 
hand  until  it  runs  hot,  the  first  flow  being  chilled  by 
running  through  the  cooler  tube.  The  sheet  is  turned 
back  to  the  knees  and  a  sterile  towel  laid  across  the  pubes : 
the  nozzle  is  then  gently  introduced  for  about  6  inches,  and 
the  douche  given  without  removing  it.  The  vagina  not 
being  guarded  by  a  sphincter,  the  douche  returns  easily 
by  the  side  of  the  nozzle,  and  a  continuous  flow  is  kept  up. 
As  the  fluid  dilates  the  cavity  the  walls  of  the  vagina  are 
stretched  and  cleansed  and  the  cervix  lies  in  a  continual 
bath,  while  the  adjacent  parts  receive  the  benefit  of  a  hot 
application.  When  the  douche  is  over,  the  nozzle  is 
removed  and  the  patient  dried  with  the  sterile  towel. 
A  douche  is  generally  given  at  a  temperature  of  from  105° 
to  110°  F.  and  higher  (115°  to  120°  F.)  if  ordered  for  the 
arrest  of  local  hemorrhage.  Very  rarely  it  is  ordered  cold. 


174  ENEMATA,   ETC. 

The  thermometer  used  in  ascertaining  the  temperature 
of  sterile  solutions  should  be  kept  in  alcohol  or  an  antiseptic 
solution  and  handled  only  with  freshly  sterilized  hands  or 
forceps. 

Sterile  water,  normal  salt  solution,  or  a  mild  antiseptic 
is  usually  employed  for  douching.  Boric  acid  is  the  mildest 
antiseptic  and  probably  the  most  frequently  used,  in  a  2 
per  cent,  solution.  (See  Solutions.)  Stronger  antiseptics, 
such  as  carbolic  or  bichlorid  of  mercury,  if  ordered,  are 
used  at  from  one-half  to  one-fourth  the  strength  used  for 
the  external  surfaces;  again  on  account  of  the  risk  of  reach- 
ing the  uterine  or  peritoneal  cavities,  and  their  absorption 
into  the  system  through  these  channels.  A  douche  of 
the  bichlorid  of  mercury,  1  : 4000,  has  been  known  to 
produce  symptoms  of  general  mercurial  poisoning.  The 
ABC  douche  in  common  use  in  some  hospitals  contains 
alum,  1  ounce;  boric  acid,  4  ounces;  carbolic  acid  crys- 
tals, 3  drams;  oil  of  peppermint,  Ij  drams;  two  drams  of 
the  powder  are  added  to  one  quart  of  sterile  water.  The 
quantity  used  for  a  douche  varies — commonly  one  to  two 
quarts  once  or  twice  a  day  are  ordered. 

Intra-uterine  Douche. — The  intra-uterine  douche  is 
never  ordered  as  a  matter  of  routine  treatment,  and  is, 
except  in  grave  emergencies,  always  given  by  the  physician. 

Unless  for  an  immediate  emergency,  such  as  a  uterine 
hemorrhage,  when  every  moment  is  valuable,  the  parts  are 
usually  prepared  as  carefully  as  for  a  vaginal  or  uterine 
operation,  the  strictest  asepsis  being  observed  throughout. 
The  patient  should  void  her  urine  before  the  preparation 
is  begun.  The  external  parts  of  the  vagina  are  washed 
with  green  soap  and  hot  sterile  water,  followed  by  a  hot 
vaginal  douche,  usually  of  bichlorid  of  mercury,  1  :  5000. 
To  cleanse  the  vagina  pledgets  of  gauze  are  used  on  a  pair 
of  long  curved  forceps  known  as  uterine  dressing  forceps. 
The  thigh  and  pubes  are  covered  with  sterile  towels  or 
by  an  examining  sheet.  Under  the  patient  is  placed  a 
Kelly  pad,  covered  also  with  a  sterile  sheet,  and  with  the 
apron  directed  into  a  bucket.  As  it  is  necessary  to  have  the 
vagina  in  a  good  light,  the  patient,  if  the  douche  is  given 
in  the  room,  lies  in  the  dorsal  (p.  229)  position  across  the 


DOUCHES  175 

bed,  the  buttocks  brought  to  the  edge  of  the  mattress; 
the  legs  are  flexed  and  supported  at  the  knee  and  heel  by 
two  assistants.  A  sterile  gown  and  gloves  are  usually  worn 
by  the  operator.  A  speculum  (p.  236)  is  passed  into  the 
vagina  and  adjusted  until  the  cervix  is  seen  in  a  good  light, 
and  the  douche  nozzle  is  then  passed  without  force  into  the 
cavity  of  the  uterus  as  far  as  the  fundus,  a  distance  of 
between  2  and  3  inches  from  the  cervix  in  the  non-gravid 
uterus.  The  nozzle  must,  of  course,  be  full  when  passed,  and 
the  first  chilled  fluid  have  been  carefully  run  off.  The  tem- 
perature of  the  douche  is  usually  115°  to  120°  F.  Special 
long  curved  douche  nozzles  are  used  for  the  intra-uterine 
douche;  if  none  are  available,  the  female  glass  catheter 
is  often  substituted.  After  the  douche  a  sterile  perineal 
pad  is  applied;  in  some  cases  the  vagina  is  lightly  packed 
with  sterile  gauze,  the  packing  remaining  until  the  next 
day. 

The  return  flow  of  the  intra-uterine  douche  should 
never  be  thrown  away  until  inspected  by  a  responsible 
person.  All  shreds,  etc.,  it  may  contain  should  be  saved 
and  shown  to  the  physician. 

When  given  immediately  after  parturition  for  the  arrest 
of  hemorrhage,  the  procedure  is  more  simple,  as  the  cervix 
is  not  only  already  dilated,  but  obliterated,  the  mouth  of 
the  uterus  being  as  wide  as  the  cavity,  and  the  parts  have 
generally  been  kept  sterile.  In  this  instance,  if  alone  with 
the  case,  a  nurse  may  have  to  act  for  herself.  The  hands 
and  arms  must  be  thoroughly  disinfected,  and  the  hands, 
if  possible,  covered  with  rubber  gloves.  The  vaginal 
douche  nozzle  will  pass  easily,  and  should  be  directed 
backward  and  then  forward  in  the  line  of  the  birth-canal 
until  the  fundus  is  felt.  The  douche  is  given  at  a  temper- 
ature of  120°  F.  It  acts  by  exciting  uterine  contractions 
and  so  closing  the  large,  open  uterine  blood-vessels.  In 
this  instance,  while  giving  the  douche  with  the  right  hand, 
the  left  hand  should  apply  massage  to  the  fundus  through 
the  abdominal  wall  in  order  to  help  in  exciting  uterine 
contractions.  It  must  then  be  remembered  that  only  the 
right  hand  is  sterile. 

When  it  is  desirable  to  enlarge  the  opening  to  the  vagina, 


170 


ENEMATA,   ETC. 


either  for  purposes  of  cleansing,  to  apply  treatment,  or 
for  examination  of  the  cavity,  a  speculum  is  passed  (p. 
236).  In  passing  the  vaginal  speculum  the  patient  may 
lie  equally  conveniently  on  her  left  side  or  on  her  back. 

The  Nasal  Douche. — Except  for  cases  of  chronic  nasal 
discharge,  the  nasal  douche  is  not  at  the  present  greatly 
used.  For  other  affections  the  spray  is  preferred.  In 
giving  it  the  usual  douche-can  may  be  used,  and  the  tub- 
ing attached  to  a  special  nasal  nozzle,  or  the  douche  may 
be  given  with  a  rubber-ball  syringe  fitted  with  a  fine  nozzle. 
The  douche-can  should  be  elevated  just  sufficiently  high 


Fig.  28. — Nasal  douching  with  fountain  syringe  (Manhattan  Eye, 
Ear,  and  Throat  Hospital  nursing  book) . 

for  the  water  to  flow;  the  usual  precaution  of  filling  the 
tube  and  nozzle  before  beginning  must  be  observed,  and 
the  first  chilled  flow  run  off.  A  basin  for  the  return  flow 
is  held  below  the  chin.  The  head  of  the  patient  should  be 
bent  forward  and  his  mouth  open;  the  tip  of  the  nose 
is  tilted  upward,  and  the  nozzle  introduced  directly  back- 
ward. In  this  position  the  fluid  enters  at  one  nostril, 
irrigates  the  posterior  nares,  and  returns  through  the  other 
nostril.  Each  nostril  is  treated  in  turn.  A  child  may  be 
told  to  breathe  audibly  during  the  process  through  his 
mouth.  This  will  prevent  his  swallowing  the  douche  or 


DOUCHES  177 

choking.  Usually  the  douche  is  given  at  a  temperature  of 
105°  to  110°  F.,  and  consists  of  sterile  water,  normal  salt 
solution,  or  some  mild  antiseptic  or  astringent  solution. 
If  given  to  arrest  hemorrhage,  as  after  some  local  operation, 
or  in  persistent  epistaxis,  the  nasal  douche  may  be  ordered 
ice  cold,  or  contain  some  styptic,  such  as  iron,  tannin,  or 
adrenalin.  More  commonly,  styptics  are  applied  by  spray 
or  direct  application 

The  Ear  Douche. — To  give  an  ear  douche  properly  is  a 
delicate  matter  and  one  not  often  intrusted  to  the  pupil 
nurse.  At  the  end  of  the  short  auditory  canal  is  the  deli- 
cate tympanum  or  drum,  upon  the  integrity  of  which  de- 
pends largely  the  power  of  hearing,  the  sound-waves  be- 
ing transmitted  through  its  vibrations  to  the  middle 
ear.  In  a  normal  condition  it  is  kept  in  a  state  of  equal 
tension  by  pressure  of  air  on  either  side — air  which  enters 
from  the  auditory  canal  externally,  and  internally  through 
the  Eustachian  tube  at  the  back  of  the  throat  to  the  cham- 
ber of  the  middle  ear.  If  this  even  relation  is  altered,  as, 
for  instance,  from  the  blocking  of  a  Eustachian  tube,  we 
get  deafness  resulting.  A  volume  of  water  directed  against 
the  tympanum  from  one  side  must  immediately  alter  the 
evenness  of  this  pressure,  and  if  directed  with  sufficient 
force  or  violence,  may  injure  or  even  permanently  impair 
the  delicate  membrane.  A  small  douche-can  and  tube 
may  be  used,  placed  only  a  few  inches  higher  than  the  ear, 
but  usually  the  douche  is  given  either  with  a  glass  or 
ball  syringe  of  soft  rubber. 

The  douche  commonly  used  is  boric-acid  solution  (2 
per  cent.).  The  temperature  of  the  douche  is  usually 
from  100°  to  105°  F.,  the  skin  being  more  sensitive  to 
heat  than  is  the  mucous  membrane.  The  patient  sits 
with  the  head  erect  in  a  good  light,  the  clothing  protected 
by  a  small  rubber  sheet  and  towel  laid  round  the  shoulders 
and  pinned  round  the  neck.  Under  the  ear  is  held  a 
small  basin,  kidney-shaped,  if  it  is  procurable,  for  the 
return  flow. 

The  auricle  or  outer  ear  is  held  slightly  backward  and 
upward  in  giving  the  douche,  which  brings  the  auditory 
canal  in  a  straighter  line  with  the  irrigating  nozzle.  The 
12 


178 


ENEMATA,   ETC. 


nozzle  must  not  be  pushed  beyond  the  opening  of  the  audi- 
tory canal  and  the  irrigation  be  carried  out  very  gently. 
When  it  is  finished,  any  moisture  is  sopped  up  from  the 
canal  with  small  pledgets  of  cotton,  changing  them  until 
perfectly  dry.  A  small  dry  pledget  is  generally  left  tem- 
porarily in  the  ear. 

The  ear  is  douched  for  the  removal  of  discharges,  in 
inflammatory  conditions,  to  allay  pain,  and  for  the  removal 


Fig.  29. — Syringing  an  ear  (Manhattan  Eye,  Ear,  and  Throat  Hos- 
pital nursing  book). 

of  impactions  of  wax  and  of  foreign  bodies,  in  which  latter 
condition  the  procedure  is  a  little  different.  (See  Foreign 
Bodies,  p.  686  )  The  facility  with  which  the  ear  may  be 
injured  by  careless  douching  cannot  be  too  greatly  em- 
phasized. 

The  Eye  Douche. — Few  details  of  nursing  are  more 
important  and  more  often  inadequately  performed  than 
the  eye  douche.  The  purpose  is  thoroughly  to  irrigate 
every  corner  of  the  conjunctival  sac;  in  point  of  fact,  the 


DOUCHES  179 

average  douche  does  little  beyond  cleansing  the  surface 
immediately  behind  the  margin  of  the  lids.  The  conjunc- 
tiva may  be  described  as  beginning  at  the  margin  of  one 
lid,  lining  the  lid,  doubling  back  to  cover  the  eyeball,  and 
again  folding  to  line  the  second  lid,  at  the  margin  of  which 
it  terminates.  By  thus  folding,  the  conjunctiva  presents 
two  surfaces  which  are  continuously  rubbing  together. 
If  the  margins  of  both  lids  are  picked  up  separately  and 
held  away  from  the  eyeball,  a  small  pouch  is  formed  lined 
entirely  by  the  conjunctiva.  This  constitutes  the  con- 
junctival  sac.  If  irrigation  is  attempted  while  the  lids 
lie  against  the  eyeball,  the  upper  and  lower  corners  of  the 
sac  are  not  reached.  The  upper  lid  first  should  be  held 
well  away  from  the  eyeball,  taking  the  margin  gently 
between  the  finger  and  thumb,  and  the  douche  thoroughly 
administered.  The  lower  portion  of  the  sac  can  be  thor- 
oughly opened  by  pulling  the  loose  tissue  of  the  under  lid 
gently  down  against  the  cheek  bone.  The  stream  should 
be  directed  from  the  inner  corner  of  the  eye  outward.  The 
patient  may  sit  on  a  chair  with  the  head  held  backward 
and  slightly  to  the  side  of  the  eye  under  treatment,  a  basin 
being  held  conveniently  to  catch  the  overflow.  A  small 
douche-can  with  about  three  feet  of  tubing  fitted  to  a 
medicine-dropper  or  fine  glass  nozzle  is  generally  used, 
though  a  small  rubber  ball  syringe  is  also  practical.  A 
glass  syringe  may  be  used,  but  has  the  disadvantage  that 
it  takes  two  hands  to  fill  it.  Some  small  sterile  cotton  or 
gauze  sponges  are  required  to  cleanse  the  lids  and  dry 
them  after  the  douche,  each  sponge  being  used  only  once 
and  discarded.  If  both  eyes  are  to  be  treated,  as  in  in- 
fectious cases,  a  second  nozzle  or  syringe  should  be  used 
to  avoid  infecting  one  eye  from  the  other,  and  the  hands 
should  be  thoroughly  rinsed  in  bichlorid  of  mercury  so- 
lution between  the  treatment.  Strict  asepsis  must  be 
observed.  In  douching  before  or  after  an  operation  the 
douche-can  should  be  elevated  about  6  inches:  where 
purulent  discharge  has  to  be  washed  away,  a  height  of 
from  12  to  18  inches  is  generally  ordered.  Force  must 
not  be  used.  The  only  instance  in  which  force  is  beneficial 
is  where  highly  irritating  matter,  such  as  quicklime,  has 


180  ENEMATA,  ETC. 

got  into  the  eye.  In  these  cases  frequently  the  only  im- 
mediately available  treatment  is  to  hold  the  eye  open 
under  a  faucet  of  running  water.  (See  Emergencies, 
Chapter  XIX.) 

In  irrigating  an  infant's  eye  the  nurse,  seated  on  a  low 
chair,  should  hold  the  baby  across  her  lap,  the  head  at 
the  edge  of  the  knee,  with  the  face  turned  from  her. 
Rolling  the  baby  in  a  small  blanket  will  pinion  the  arms 
and  prevent  struggling.  A  piece  of  rubber  sheeting  with 
a  circular  piece  cut  out  of  one  end  is  fastened  round  the 
baby's  neck  so  that  the  clothes  are  protected,  and  at  the 
same  time  the  cheek  rests  on  the  rubber.  The  free  end  of 
the  sheeting  is  caught  into  a  clean  vessel  on  the  floor. 
The  nurse  has  then  both  hands  free — one  to  open  the  lids, 
the  other  to  manipulate  the  nozzle.  In  order  that  dis- 
charge may  not  run  across  the  nose  from  one  eye  to  be 
other  the  head  must  be  turned  toward  the  side  of  the  eye 
to  be  treated.  The  nozzle  is  directed  toward  the  inner 
corner,  so  that  the  discharge  is  washed  outward.  If 
only  one  eye  is  to  be  treated,  the  sound  eye  should  be  pro- 
tected by  a  sterile  pad  or  covered  with  a  watch-glass 
during  the  process. 

In  the  case  of  ophthalmia  neonatorum,  the  ophthalmia 
of  the  new-born,  when  want  of  thoroughness  may  result 
in  permanent  blindness,  it  should  be  a  strict  rule  that  the 
douching  should  be  done  by  two  nurses.  To  open 
the  swollen  lids  thoroughly  takes  one  pair  of  hands  en- 
tirely, and  it  is  of  the  first  importance  that  every  corner 
of  the  sac  should  be  freely  exposed  to  the  douching. 

TAMPONS 

The  Vaginal  Tampon. — The  tampon  is,  at  the  present 
day,  not  in  constant  use;  a  nurse  should,  however,  be 
instructed  how  to  prepare  and  how  to  insert  one. 

Tampons  are  usually  made  of  absorbent  cotton,  cut 
into  strips  three  inches  wide,  rolled  tightly  into  little 
bolsters,  and  tied  round  the  center  with  securely  knotted 
silk  or  string,  the  ends  of  which  are  sufficiently  long  to 
come  beyond  the  mouth  of  the  vagina  when  the  tampon  is 
in  position.  Two  or  three  may  be  tied  a  few  inches  apart 


TAMPONS  181 

on  one  string,  forming  what  is  known  as  a  kite-tail  tampon. 
The  tampon  is  sterilized  and  usually  saturated  with  gly- 
cerin (sterile),  1  part,  to  sterile  water,  2  parts,  but  it 
may  also  be  soaked  in  any  solution  which  it  is  desirable 
to  apply  to  the  parts.  Strict  aseptic  technic  is,  of  course, 
to  be  observed. 

To  introduce  the  tampon  the  patient  lies  on  her  back 
with  the  knees  flexed  and  separated;  the  speculum  is 
passed  and  held  in  position  with  the  left  hand.  The  tam- 
pon is  then  taken  by  the  right  hand  in  a  pair  of  long  for- 
ceps,— those  usually  called  uterine  dressing  forceps, — and 
passed  up  to  the  pouch-like  cavity  between  the  cervix  and 
the  posterior  vaginal  wall.  The  speculum  is  withdrawn, 
and  the  ends  of  string  looped  together  and  laid  just  inside 
the  vagina,  where  they  will  not  be  soiled  by  urine,  etc. 
A  record  must  always  be  made  on  the  chart  of  any  tampon 
inserted  in  the  vagina;  if  more  than  one,  or  a  kite-tail 
tampon  is  used,  the  number  must  be  noted  and  carefully 
counted  on  withdrawal.  The  withdrawal  also  should  be 
noted  on  the  chart.  The  withdrawal  is  done  by  gently 
pulling  on  the  strings,  and  presents  no  difficulty.  If  the 
tampon  is  for  continuous  treatment  it  is  changed  daily, 
and  usually  given  in  connection  with  a  daily  douche. 

To  Pack  a  Vagina. — This  is  not  often  left  to  a  hospital 
nurse  unless  in  small  hospitals,  where  there  is  no  resident 
medical  staff.  She  should,  however,  be  taught  how  to 
do  it  in  case  of  just  such  circumstances.  Under  strict 
aseptic  precautions  the  speculum  is  passed,  the  patient 
lying  on  her  back  in  a  good  light,  with  the  knees  flexed 
and  separated;  a  long  strip  of  sterile  gauze  or  a  narrow 
gauze  bandage  is  then  packed  into  the  space  between 
the  cervix  and  vaginal  walls,  using  a  pair  of  uterine 
dressing  forceps  and  playing  out  the  packing  inch  by  inch. 
The  rest  of  the  cavity  is  then  packed,  withdrawing  the 
speculum  gradually.  If  more  than  one  strip  is  used,  the 
number  must  be  recorded  on  the  chart  and  counted  when 
they  are  removed.  If,  on  removal,  any  odor  is  noticed  on 
the  packing,  it  should  be  reported  at  once,  when  an  anti- 
septic douche  will  generally  be  ordered.  It  should  not, 
however,  be  given  without  special  orders;  the  conditions 


182  ENEMATA,  ETC. 

which  necessitate  packing  would  frequently  not  be  bene- 
fited by  the  relaxation  of  the  parts  by  douching. 

CATHETERIZATION 

A  catheter  is  a  slender  hollow  instrument  of  small  cal- 
iber, open  at  either  end,  used  in  the  treatment  of  certain 
tube-like  passages  in  the  body  or  of  the  cavities  to  which 
the  passages  lead.  The  hollowness  of  the  instrument 
permits  the  evacuation  of  the  contents  of  the  cavity,  and 
of  the  introduction  of  certain  forms  of  treatment,  such  as 
douching,  etc. 

The  catheters  in  most  common  use  are  those  for  introduc- 
tion into  the  bladder  through  the  urethra,  and  are  what 
are  implied  when  the  word  catheter  is  used  unqualifiedly. 


Fig.  30. — Tray  with  necessaries  for  catheterization. 

Those  used  for  a  female  patient  are  made  of  glass,  silver, 
soft  rubber,  or  hard  rubber.  The  glass  catheter  is  gener- 
ally preferred,  being  easily  cleaned  or  sterilized  and  in- 
expensive. It  is  about  6  inches  in  length  and  J  inch  in 
diameter;  the  tip  is  solid,  rounded,  and  slightly  bent,  with 
an  opening  or  eye  on  one  side.  If  a  less  rigid  instrument  is 
desired,  as  after  an  operation  on  an  adjacent  part,  the 
soft-rubber  variety  is  substituted. 

Soft-rubber  or  gum-elastic  catheters  are  about  12  inches 
long,  and  come  in  various  sizes;  the  sizes  are  indicated  in 
numbers  printed  on  the  catheter.  Three  scales  of  number- 
ing are  in  use — American,  English,  and  French;  it  is 


CATHETERIZATION  183 

important  in  ordering  catheters  to  mention  which  scale  is 
intended,  as  each  is  different. 

A  pupil  should  not  be  trusted  to  pass  a  catheter  until 
she  has  had  some  instruction  in  the  principles  of  asepsis, 
and  been  carefully  taught  the  technic  of  this  particular 
process. 

It  is  recommended  that  a  list  of  the  articles  required  for 
catheterization  with  simple  directions  for  the  technic  to 
be  observed  should  be  written  down  and  hung  in  some 
readily  available  position  (Chapter  XIV) .  Time  is  saved 
if  a  tray  is  kept  in  readiness  with  all  the  articles  neces- 
sary. Such  a  tray  should  contain : 

2  towels,  ] 

6  gauze  sponges,  [•  Sterile,  in  sterile  wrappers. 

1  small  flat  bowl  (to  receive  the  urine)  J 

1  bowl  of  hot  boric  lotion  (2  per  cent.)  for  cleansing  the  parts. 

2  glass  catheters  (boiled  five  minutes  and  placed  in  the  boric  lotion) . 
1  large  bowl  or  graduate  measure  of  sufficient  capacity  to  contain 

all  the  urine. 

A  bowl  of  hot  antiseptic  lotion  (bichlorid  of  mercury, 
1  : 2000,  etc.)  must  also  be  prepared,  in  case  the  nurse 
accidentally  breaks  the  technic. 

The  hands  are  prepared  according  to  the  ward  formula 
(p.  508,  formula  B,  in  ordinary  circumstances);  gown  and 
gloves  are  not  usually  required. 

Before  cleansing  her  hands  the  nurse  prepares  her  tray, 
unpins  the  sterile  wrappers,  and  places  everything  in 
readiness  by  her  patient's  bedside;  if  she  works  alone,  she 
must  also  place  her  patient  in  position,  covering  her  tem- 
porarily with  a  single  sheet,  which  the  patient  can  herself 
usually  turn  out  of  the  way  when  the  nurse  is  "  clean," 
the  sheet  not  being,  surgically  considered,  "  clean."  A 
second  nurse,  when  available,  should,  for  the  patient's 
comfort,  carry  out  this  part  of  the  technic  so  as  to  avoid 
the  necessary  waiting. 

The  patient  lies  on  her  back,  with  the  knees  drawn  up 
and  separated;  the  night-dress  is  rolled  up  round  the 
waist,  the  heavier  bed-clothes,  for  convenience,  turned  back 
over  the  feet.  The  covering  sheet  is  turned  back  to  the 
knees  just  sufficiently  for  the  necessary  exposure.  The 


184  ENEMATA,    ETC. 

sterile  towels  are  arranged  one  across  the  pubes,  one  on 
the  bed  below  the  vulva;  the  small  sterile  basin  is  placed 
close  to  the  vulva,  to  receive  the  urine,  which  is  emptied, 
as  required,  into  the  larger  bowl.  The  sterile  area  must  be 
kept  sterile  during  the  entire  proceeding. 

To  pass  the  catheter  the  nurse  stands  on  the  right  of 
the  patient;  passing  her  left  hand  between  the  knees,  over 
the  pubes,  she  separates  the  labia  and  with  her  right  hand 
thoroughly  cleanses  the  parts  of  all  secretion,  using  the 
sponges  wrung  nearly  dry  in  the  hot  boric  lotion. 

The  opening  of  the  urethra  (urinary  meatus)  is  seen  as  a 
small  round  depression  or  "  dimple  "  with  slightly  raised 
edges  immediately  in  front  of,  or,  as  the  patient  lies,  above, 
the  larger  opening  of  the  vagina. 

The  catheter  is  taken  in  the  right  hand  and  introduced 
into  the  urethra,  pushing  it  gently  forward  a  few  inches 
until  the  urine  flows,  and  no  further;  no  force  must  be  used. 

When  the  urine  stops,  the  catheter  should  be  withdrawn 
slightly,  when  the  flow  will  probably  begin  again;  as  the 
bladder  empties  the  level  of  the  urine  may  be  lower  than 
the  edge  of  the  catheter,  so  that  the  first  stopping  of  the 
flow  does  not  necessarily  mean  that  the  bladder  is  quite 
empty. 

When  no  more  urine  comes,  the  catheter  is  withdrawn, 
keeping  the  finger  over  the  free  end  of  the  catheter  in 
order  not  to  lose  the  last  small  quantity  remaining  in  the 
catheter:  being  the  last  left  in  the  bladder,  it  is  often  of 
special  diagnostic  importance. 

The  vulva  is  then  once  more  sponged  and  dried  with  one 
of  the  sterile  towels,  after  which  the  nurse  rinses  and 
dries  her  own  hands  and  arranges  her  patient  comfortably. 

When  catheterization  is  ordered  for  the  relief  of  an  over- 
distended  bladder,  the  entire  quantity  should  not  be  with- 
drawn at  one  time,  some  being  left  in  the  bladder,  which 
is,  if  necessary,  removed  later  by  catheter.  The  tumor 
formed  by  a  distended  bladder  may  be  observed  through 
the  abdominal  wall.  When  empty,  the  bladder  lies  behind 
the  pelvic  bone. 

The  greatest  care  must  be  taken  to  keep  the  catheter 
clean  during  the  entire  proceeding;  that  the  catheter  should 


CATHETEKIZAT1OM  185 

be  clean  and  strictly  sterile  is  the  most  important  part  of 
the  technic.  If  it  becomes  soiled  with  blood  or  vaginal 
secretion,  it  is  not  enough  to  rinse  it  clean  in  solution :  the 
catheter  must  not  be  used  unless  resterilized  by  washing 
and  boiling.  It  is,  for  this  reason,  a  wise  precaution  always 
to  prepare  more  than  one  catheter  each  time.  Where  any 
vaginal  discharge  is  present,  a  gauze  sponge  must  be  held 
over  the  vaginal  orifice  during  the  whole  operation. 

After  an  operation  on  the  perineum  or  adjacent  parts 
nurses  are  usually  required,  in  passing  the  catheter,  to 
wear  a  gown  and  gloves,  and  the  hands  are  prepared  by  a 
stricter  formula  (p.  508,  formula  A).  An  extra  packet 
of  sponges  and  a  perineal  pad  should  then  be  prepared. 
In  these  circumstances  a  soft-rubber  catheter  may  be 
preferred  to  the  rigid  glass  catheter.  A  rubber  catheter 
requires  to  be  lubricated  with  a  very  little  sterile  oil; 
with  a  glass  catheter  it  is  sufficient  to  wet  the  catheter  in 
the  boric  solution. 

The  nurse  should  observe  the  stream  of  urine  closely. 
If  blood,  pus,  or  any  sediment  is  present,  it  is  of  importance 
to  know  if  such  was  mixed  with  the  entire  quantity  of 
urine,  or  was  present  only  at  the  beginning  or  only  at  the 
end  of  the  catheterization.  She  should  observe  whether 
the  urine  was  passed  clear  or  cloudy,  and  whether  it  changed 
in  any  way  on  becoming  cool.  (See  Urine.)  She  may 
be  directed  to  keep  the  first  or  last  of  the  flow  separate 
from  the  rest  of  the  urine,  in  which  case  the  desired 
specimen  is  passed  from  the  catheter  directly  into  a  sterile 
test-tube,  corked  at  once  with  sterile  cotton.  If  a  speci- 
men of  the  urine  is  required  for  examination,  a  sufficient 
quantity  (6  ounces)  is  passed  directly  into  a  sterile  bottle 
or  jar  and  closely  covered  or  corked  with  sterile  cotton; 
a  note  must  be  made  on  the  label  that  the  specimen  was 
obtained  by  catheterization. 

Where  strict  aseptic  cleanliness  is  observed,  catheteriza- 
tion is  followed  by  no  untoward  consequences.  Care- 
lessly performed,  with  impartially  cleansed  catheter  or 
hands  or  imperfect  technic,  the  simple  process  may  be  a 
prolific  source  of  infection  by  introducing  germs  or  im- 
purities into  the  bladder.  The  signs  of  such  infection  are 


186  ENEMATA,  ETC. 

rigor  (or  shivering),  followed  by  high  temperature,  alkaline 
urine,  and  the  general  physical  symptoms  of  a  septic 
condition.  The  cystitis  or  inflammation  of  the  bladder 
thus  induced  may  last  many  weeks. 

A  few  patients  are  subject  to  shivering  attacks  of  ner- 
vous origin  after  prolonged  catheterization.  Frequently 
this  may  be  averted  by  covering  the  patient  warmly  during 
the  operation  and  giving  immediately  a  glass  of  hot  milk. 

Bladder  Irrigation. — The  same  technic  as  above  is 
observed  in  irrigating  a  bladder,  and  catheterization  is 
always  performed  as  a  preliminary  proceeding.  Irriga- 
tion is  most  simply  performed  with  the  double  catheter, 
a  catheter,  that  is,  having  a  double  channel  and  double 
opening,  each  opening  having  an  independent  short  arm. 
They  can  be  obtained  in  glass  or  metal,  glass  being  pre- 


Fig.  31. — Double  catheter  for  bladder  irrigation. 

ferred.  To  each  arm  a  piece  of  tubing  is  attached,  one 
connected  with  a  douche-can  or  a  funnel,  the  other  reach- 
ing to  a  convenient  receptacle  for  the  return  flow.  The 
return  tube  is  clamped  until  the  quantity  that  can  be 
retained  without  pain  has  been  injected  into  the  bladder. 
The  quantity  is  usually  about  half  a  pint.  Sterile  water 
or  boric  solution,  2  per  cent.,  is  generally  used,  at  a  tem- 
perature of  100°  to  110°  F.,  and  1  or  2  pints  given  at  a 
time.  The  catheter  must  be  filled  before  insertion  and 
the  fluid  run  off  "it  until  it  runs  hot.  The  douche-can 
should  not  be  elevated  more  than  two  feet. 

When  a  double  catheter  is  not  attainable,  the  funnel 
and  tube  may  be  used.  About  half  a  pint  (8  to  10  ounces) 
is  injected  first;  the  tube  is  then  lowered,  and  half  the 
quantity  siphoned  off;  injections  of  4  or  5  ounces  are  re- 
peated and  siphoned  off  until  the  bladder  is  sufficiently 


CATHETERIZATION  187 

irrigated.  In  order  to  keep  the  tube  filled  with  fluid  it 
must  be  carefully  pinched  between  the  siphoning  and  the 
injection,  but  even  with  this  precaution,  it  is  difficult  to 
avoid  introducing  air  into  the  bladder  unless  the  catheter 
is  reinserted  each  time,  which  is  obviously  undesirable. 

The  Guarded  Catheter. — After  operations  on  the 
bladder  or  adjacent  parts,  it  is  sometimes  necessary  to 
leave  a  catheter  permanently  in  place.  In  order  that  it 
should  not  slip,  a  special  rubber  catheter  may  be  used, 
made  with  an  enlargement  just  below  the  eye,  usually 
shaped  either  like  an  arrow-head  or  a  button.  To  insert 
or  withdraw  such  a  catheter  the  enlargement  is  for  the 
moment  obliterated  by  stretching  the  upper  part  of  the 
catheter  tightly  over  a  long  dressing  probe  or  similar  in- 
strument, and  passing  it  while  still  stretched.  As  soon 
as  the  tension  is  removed  by  withdrawing  the  probe  the 
shape  is  resumed.  The  catheter  is  connected  by  a  glass 
connection  tube  with  a  piece  of  tubing,  which  may  be  in- 
serted in  a  bottle  tied  to  the  frame  of  the  bedstead;  it  is 
removed  at  least  once  in  twenty-four  hours,  cleansed,  ster- 
ilized, and  reinserted.  As  the  eye  of  the  catheter  may 
easily  become  blocked,  especially  after  operations  where 
small  blood-clots  may  be  present,  it  is  always  necessary  in 
these  cases  to  keep  close  watch  that  the  urine  is  flowing 
regularly. 

To  pass  a  guarded  catheter  or  to  pass  a  catheter  over  a 
surface  where  tissues  have  been  stitched  requires  a  great 
deal  of  skill,  and  should  never  be  intrusted  to  young,  in- 
experienced nurses.  All  nurses  should  also  be  taught 
to  pass  the  catheter  with  the  patient  lying  on  her  side,  a 
position  which  presents  no  real  difficulties.  Where  a 
fixed  position  is  necessary,  it  may  be  impossible  to  turn  the 
patient,  even  for  so  short  a  time,  on  to  her  back. 

After  use,  a  catheter  must  be  immediately  washed  under 
a  running  stream  of  cold  water,  since  hot  water  would 
coagulate  any  albumin  which  might  be  present,  then 
washed  in  hot  soap  and  water,  and  boiled  for  five  minutes; 
before  use  it  is  again  sterilized  by  boiling.  (See  Care  of 
Catheters,  p.  486.) 

The  Male  Catheter. — To  pass  a  male  catheter  is  not 


188  ENEMATA,    ETC. 

taught  to  pupil  nurses,  and  is  never  included  in  the  duties 
expected  of  a  nurse. 

On  the  very  rare  occasions  in  which  an  emergency  should 
force  this  duty  on  her,  she  should  employ  the  same  careful 
technic  taught  her  in  passing  the  female  catheter.  A 
soft-rubber  catheter  lubricated  with  a  sterile  lubricant  is 
used.  The  penis  is  washed  (boric  lotion,  2  per  cent.)  and 
the  foreskin  gently  pushed  back.  The  glans  and  meatus 
are  then  cleansed.  Holding  the  penis  rather  more  than 
halfway  between  horizontal  and  perpendicular,  the  cath- 
eter is  gently  inserted  and  pushed  forward.  If  resistance 
is  met,  as  usually  happens,  force  must  on  no  account  be 
used;  if  the  catheter  is  held  in  position  for  a  short  time 
and  again  gently  pushed  forward,  it  will,  in  ordinary  con- 
ditions, slip  into  the  bladder.  If  it  cannot  be  passed 
without  force,  the  attempt  must  be  abandoned;  matters 
will  not  be  improved,  and  serious  harm  is  easily  done. 

LAVAGE 

In  certain  conditions,  such  as  in  cases  of  poisoning,  or 
in  the  treatment  of  some  diseases  of  the  stomach  and  for 
purposes  of  diagnosis,  it  becomes  necessary  to  remove  the 
gastric  contents  and  thoroughly  to  irrigate  the  stomach. 
The  process  is  known  as  lavage. 

A  rubber  tube  of  fairly  large  caliber  and  a  yard  or 
more  in  length  is  used.  The  special  tubes  sold  for  the 
purpose  are  of  non-collapsible  soft  rubber;  the  end  for  in- 
sertion is  conical,  with  an  opening  in  the  center;  the  other 
is  furnished  with  a  funnel.  The  tubes  come  in  several 
sizes,  which  are  numbered  according  to  French,  English, 
and  American  scales,  like  the  soft  catheters.  A  mark  18 
inches  below  the  insertion  end  of  the  tube  indicates  the 
length  to  be  swallowed.  The  operation  is  carried  out  most 
conveniently  with  the  patient  seated  on  a  low  chair,  but  in 
many  circumstances  the  recumbent  position  is  necessary 
and  presents  no  real  difficulty.  If  a  lavage  is  given  quietly 
and  skilfully,  there  should  be  no  mess;  it  is  well,  however, 
in  case  of  accident  to  protect  the  clothing  with  a  rubber 
sheet,  and  to  have  a  second  also  on  the  floor.  A  bucket 


LAVAGE 


189 


is  required  to  receive  the  contents  of  the  stomach,  and  a 
pitcher  of  a  suitable  size  for  pouring  with  one  hand  contains 
the  fluid  for  the  lavage.  The  tube  is  moistened  with  hot 
water  or  lubricated  with  glycerin  (oil  is  unpalatable),  and 
passed  to  the  back  of  the  tongue.  If  the  patient  remains 
quiet  and  will  help  by  swallowing,  the  tube  then  slides  easily 
over  the  epiglottis  into  the  esophagus  by  way  of  the  phar- 
ynx and  so  into  the  stomach.  From  18  to  20  inches  of  the 


V  HJHMUillJHHMBilM 

Fig.  32. — Lavage,  first  step.     Introduction  of  tube  (Crandon). 

tube  are  sufficient  to  reach  the  stomach.  Many  patients, 
however,  struggle  violently,  and  to  pass  the  stomach-tube 
requires  patience  and  skill.  If  the  patient  is  unconscious, 
the  tube  should  be  left  in  position  a  few  minutes  after 
passing,  to  make  certain  that  it  has  not  by  accident  been 
passed  into  the  trachea,  where,  if  the  lavage  was  given, 
the  patient  would  be  instantly  drowned.  If  the  patient 
breathes  naturally  and  does  not  become  cyanosed,  and  if  it 
is  ascertained,  by  holding  the  tube  against  the  cheek,  that 


190 


ENEMATA,    ETC. 


no  air  is  being  breathed  through  the  tube,  all  is  well  and 
the  operation  can  proceed.  To  pass  a  tube  into  the  trachea 
is  an  extremely  difficult  thing  to  do,  and  were  it  not  that 
such  accidents  are  on  record,  the  warning  would  seem  to 
have  little  practical  significance.  The  danger,  however, 
must  not  be  overlooked.  The  funnel  is  held  about  one 
foot  above  the  patient's  head,  and  as  much  water  is  poured 
into  the  stomach  as  it  will  easily  contain.  This  varies 
from  \  pint  to  2  pints,  according  to  the  age  of  the  patient; 


Fig.  33. — Lavage,  second  step.     Tube  in  stomach;  wash-water  being 
poured  into  funnel  (Crandon) . 


a  still  larger  quantity  is  used  if  the  stomach  is  dilated. 
The  funnel  is  then  lowered  over  the  bucket,  and  the  con- 
tents of  the  stomach  in  this  manner  siphoned  off.  The 
process  is  repeated  usually  until  the  water  is  returned  per- 
fectly clear.  In  some  cases  of  chronic  gastritis  or  dilata- 
tion of  the  stomach  several  gallons  may  be  used  at  one 
time. 


LAVAGE 


191 


In  some  chronic  affections  of  the  stomach  lavage  is  given 
as  a  regular  treatment;  it  should  then  be  performed  daily 
before  breakfast.  Warm  sterile  water  is  generally  used  for 
regular  treatment,  or  warm  normal  salt  solution.  A  weak 
solution  of  nitrate  of  silver  (1  :  5QOO  to  1  :  10,000  of  plain 
sterile  water)  is  ordered  in  many  chronic  conditions.  For 
acute  indigestion  bicarbonate  of  soda  (30  grains  to  a 
quart  of  water)  is  efficacious.  If  the  lavage  is  given  for 


Fig.  34. — Lavage,  third  step.     Suction  and  siphonage  (Crandon). 


the  removal  of  poisons  from  the  stomach,  the  lavage  will 
probably  contain  an  antidote  to  the  drug.  (See  Poisons, 
Chapter  X.) 

(For  Test-meals,  see  Chapter  VII,  p.  258.) 

It  is  a  nurse's  duty  to  see  that  all  the  details  of  a  lavage 

are  accurately  charted,  such  as  the  amount  used  before 

returning  clear,  etc.;  in  cases  of  suspected  poisoning  the 

gastric  contents  must  invariably  be  saved  for  inspection. 


192  ENEMATA,  ETC. 

GAVAGE 

Gavage,  or  forced  feeding,  is  resorted  to  in  those  con- 
ditions when,  from  circumstance  or  existing  impediment, 
a  patient  cannot  be  fed  in  the  natural  way:  for  example, 
in  feeding  insane  patients  who  refuse  their  food,  in  tetanus 
where  the  jaws  are  locked,  after  some  operations  on  the 
jaw,  in  feeding  unconscious  patients,  and  sometimes  in 
cases  of  extreme  weakness,  where  to  feed  otherwise 
causes  a  struggle  exhausting  to  the  patient.  Where  the 
stomach-tube  can  be  passed,  a  short  stomach-tube  and 
glass  funnel  may  be  used,  but  usually  nasal  feeding  causes 
less  disturbance  to  the  patient. 

NASAL  FEEDING 

A  soft-rubber  catheter  attached  to  a  funnel,  the  most 
practical  of  which  is  the  barrel  of  a  large  glass  syringe,  is 
passed  through  the  nostril  straight  backward  to  the  back 
of  the  throat,  and  thence  to  the  esophagus  and  stomach. 
The  catheter  may  be  lubricated  with  glycerin  or  simply  wet 
with  water.  When  in  position,  a  few  moments  are  allowed 
to  elapse  until  any  reactionary  retching  induced  has  passed, 
and  also  to  make  certain  the  tube  is  in  position,  and  the 
food  in  liquid  form  is  poured  down  the  funnel.  The  food 
should  be  given  slowly,  the  flow  being  easily  regulated  by 
pinching  the  tube.  Milk,  eggs,  thin  strained  broths,  beef- 
juice,  or  beef-essences  may  be  administered  in  this  way. 
The  feeding  is  generally  repeated  every  three  or  four  hours. 
After  the  food  is  administered  the  catheter  is  quickly 
withdrawn,  unless,  as  may  be  ordered  in  certain  conditions, 
the  tube  is  left  in  position.  When  this  is  the  case,  a  strand 
of  silk  is  threaded  through  the  tube  and  looped  round  the 
ear.  To  pass  the  tube  for  nasal  feeding  is  not  difficult, 
but  must  be  done  with  watchful  care.  The  tube  is  apt  to 
curl  on  itself  at  the  back  of  the  throat;  if  the  fluid  is 
poured  down  while  in  this  position,  it  escapes  into  the 
mouth,  causing  choking,  gasping,  and  the  consequent 
almost  certain  introduction  of  some  of  the  fluid  into  the 
trachea.  A  sufficient  quantity  would  drown  the  patient  at 
once,  but  even  a  very  small  quantity  has  dangerous  re- 


NASAL   FEEDING  193 

suits.  No  digestion  goes  on  in  the  trachea  or  lungs;  food, 
therefore,  that  lodges  in  any  part  of  the  respiratory  tract 
undergoes  decomposition,  which  may  result  in  septic 
pneumonia.  The  finger  should  be  passed  to  the  back  of 
the  tongue  after  the  tube  is  inserted,  to  make  sure  it  is 
in  the  right  position. 

In  giving  a  feeding  it  is  not  necessary  that  the  tube 
should  reach  as  far  as  the  stomach.  If  it  is  merely  passed 
3  or  4  inches  into  the  esophagus,  there  is  less  risk  of  excit- 
ing regurgitation. 

The  possibility  of  passing  the  catheter  into  the  trachea 
must  again  be  borne  in  mind,  as  to  give  the  feeding  in  this 
position  would  cause  instant  death  by  drowning.  Unless 
unduly  flustered  by  nervousness,  it  would  be  nearly  im- 
possible to  overlook  the  symptoms  enumerated  above, 
caused  by  such  an  accident.  The  risk  of  accidents  is 
lessened  by  turning  the  head  during  the  entire  process  to 
one  side,  or,  if  the  patient  is  in  a  chair,  by  keeping  the  head 
bent  slightly  forward. 

With  irritable,  semiconscious  patients  in  conditions  of 
serious  weakness  nasal  feeding  is  generally  infinitely  less 
exhausting  to  them  than  any  other  method  of  feeding. 
Especially  is  this  the  case  with  young  children  or  infants 
too  feeble  to  suck.  In  giving  nasal  feeding  to  an  infant 
it  should  be  laid  across  the  knees,  the  head  turned  slightly 
with  the  face  away  from  the  nurse,  and  the  tube  intro- 
duced in  the  nostril  uppermost. 

In  many  people  the  bony  cavity  of  one  nostril  is  larger 
than  the  other;  if  any  difficulty  is  encountered  in  passing 
the  tube,  it  may  be  removed  and  inserted  in  the  other 
nostril,  and  in  most  cases  is  then  easily  passed. 

13 


CHAPTER  V 

TEMPERATURE.— PULSE.— RESPIRATION- 
CHARTS 

TEMPERATURE 

BY  the  temperature  of  the  body  we  mean  its  degree 
of  heat.  Normally,  this  is  98.4°  F.,  that  is  to  say,  higher 
than  the  atmosphere  in  which  the  average  human  being 
can  live  with  comfort.  This  temperature  is  maintained  by 
the  perfect  balance  between  the  heat-producing  and  heat- 
losing  properties  of  the  body.  Heat  in  the  body  is  the 
result  of  chemical  changes  in  the  tissues.  The  production 
of  heat  is  increased  by  the  digestion  and  absorption  of 
food  and  by  exercise.  Heat  is  lost  through  the  skin 
surface  by  evaporation,  by  perspiration,  and  through  the 
lungs  by  expired  air.  Some  of  this  loss  is  checked  by 
clothing. 

A  deviation  from  the  normal  temperature  means  a  devia- 
tion from  the  normal  condition  of  the  body,  though  in 
health  there  is  a  fractional  degree  of  difference  between 
the  temperature  taken  in  the  morning  and  that  taken  in 
the  evening. 

Deviations  from  the  normal  temperature  are  described 
in  the  following  terms: 

Algid  collapse,   below  95°  F. 

Collapse,  95°-97°F. 

Subnormal,        97°-98.5°  F. 

Normal,  98.5°  F. 

Slightly  raised,  99°-100°  F. 

Fever,  100°-103°  F. 

Pyrexia,  103°-106°  F. 

Hyperpyrexia,  106°  F.  and  over. 

The  extremities  of  temperature,  if  maintained,  are 
fatal  to  life. 

194 


TEMPERATURE  195 

The  temperature  in  health  is  affected  by  age,  tempera- 
ment, and  idiosyncrasy.  In  infancy  the  temperature  is 
normally  from  one  to  one  and  one-half  degrees  above  that 
of  an  adult,  gradually  decreasing  as  childhood  progresses. 
In  old  age  a  -subnormal  temperature  is  common.  Per- 
sons of  an  excitable  temperament  are  apt  to  have  a  temper- 
ature higher  than  those  who  are  not  excitable.  A  few 
persons  are  met  in  whom  the  temperature  is  very  easily 
upset,  and  these  show  a  high  degree  of  fever  for  slight 
causes.  This  may  be  idiosyncrasy,  or  the  result  of  a 
previous  illness  associated  with  hyperpyrexia,  such  as 
sunstroke.  Persons  leading  sedentary  or  confined  lives 
usually  show  a  lower  average  temperature  than  those  who 
live  out-of-doors  or  take  much  exercise.  In  health  the 
temperature  is  elevated  as  a  result  of  exercise,  excitement, 
and  the  absorption  of  food;  it  is  lowered  during  digestion 
and  sleep,  after  perspiration,  after  cold  bathing,  and  from 
the  effects  of  starvation  and  exposure  to  cold. 

The  temperature  may  be  reduced  artificially  by  the  use 
of  certain  drugs,  known  for  this  reason  as  the  antipyretics, 
such  as  phenacetin,  acetanilid,  etc.,  and  by  the  application 
of  cold  to  the  surfaces.  Cold,  we  have  seen,  is  applied 
locally  in  the  form  of  ice-bags,  ice-poultices,  ice-compresses, 
and  ice-coils,  and  generally  by  baths,  sponging,  ice-crad- 
ling, ice-sprinkling,  rubbing  with  ice,  by  cold  packs,  and 
by  enteroclysis  of  cold  normal  salt  solution.  The  tem- 
perature is  also  lowered  by  large  doses  of  alcohol,  and 
frequently  also  after  the  use  of  morphin. 

The  temperature  may  be  raised  artificially  by  small 
doses  of  alcohol,  by  hot  drinks,  and  by  the  ingestion  of 
food,  by  the  use  of  cardiac  stimulants,  such  as  atropin, 
strychnin,  etc.,  and  by  external  heat,  as  in  the  form  of 
hot-water  bags,  hot  foot-baths,  hot  mustard-baths,  hot 
coffee  enemata,  hot  enteroclysis,  and  the  subcutaneous 
injection  of  hot  sterile  normal  salt  solution. 

Certain  diseases  are  characterized  by  a  marked  rise 
in  temperature.  Among  the  most  important  of  these  are 
the  acute  infectious  fevers,  acute  inflammations,  such  as 
peritonitis  and  appendicitis;  toxic  conditions,  such  as 
septicemia,  uremia,  and  ptomain  poisoning;  acute  func- 


196     TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 

tional  disturbances,  such  as  heart  disease  and  nephritis; 
heat  apoplexy,  and,  frequently,  hysteria.  Long-continued 
pain  is  also  frequently  accompanied  by  a  rise  of  tempera- 
ture. The  temperature  is  subnormal  in  conditions  of 
sudden  loss  of  vitality,  such  as  shock,  and  in  chronic 
diseases  which  are  accompanied  by  impaired  vitality, 
such  as  chronic  nephritis,  some  forms  of  heart  disease, 
etc.;  in  conditions  accompanied  by  unusual  loss  of  fluid 
to  the  body,  such  as  Asiatic  cholera  and  severe  hemorrhage; 
in  anemia,  jaundice,  diabetes,  and  in  many  forms  of  men- 
tal derangement.  It  is  subnormal  during  convalescence 
from  diseases  where  the  temperature  has  been  high,  and 
after  a  crisis.  A  condition  of  extreme  low  temperature 
accompanied  by  marked  depression  of  vitality  is  spoken  of 
as  collapse. 

After  the  temperature  has  been  raised,  it  will  return  to 
normal  in  one  of  two  ways : 

First :  By  direct  fall  to  normal  or  below  in  comparatively 
few  hours,  accompanied  by  a  decrease  in  the  pulse-rate 
and  the  number  of  respirations  per  minute,  by  a  general 
improvement  in  the  patient's  condition,  and,  usually,  by 
profuse  perspiration  (diaphoresis),  and  by  the  passage  of 
an  increased  quantity  of  urine  (diuresis) ;  this  is  known  as 
a  crisis.  Diseases  in  which  the  fever  falls  in  this  way  are 
pneumonia,  measles,  malaria,  and  typhus  fever.  Ery- 
sipelas and  influenza  also  frequently  terminate  by  a  crisis 
when  uncomplicated. 

A  crisis  must  not  be  confused  with  a  very  serious  condi- 
tion in  which  the  temperature  falls  suddenly,  while  the 
pulse-rate  increases,  and  the  patient's  condition  is  alarm- 
ingly worse  instead  of  improved.  Such  a  fall  is  seen  as  a 
characteristic  symptom  in  severe  hemorrhages,  in  perfora- 
tion, and  frequently  occurs  immediately  before  death;  it 
is  always  a  grave  symptom. 

Second:  In  practically  all  other  fevers  the  temperature 
declines  gradually,  taking  several  days  to  reach  the  normal, 
and  maintaining,  in  its  descent,  the  usual  difference  be- 
tween the  morning  and  evening  temperature.  Tempera- 
ture falling  in  this  way  is  said  to  fall  by  lysis. 

Where  the  temperature  rises  abruptly  at  the  beginning 


TEMPERATURE 


197 


of  an  illness,  we  say  the  disease  is  characterized  by  a 
sudden  onset;  where  the  temperature  rises  slowly  from  day 
to  day,  with  morning  remissions,  we  speak  of  the  onset  as 
gradual.  The  sudden  onset  is  generally  accompanied  by 
rigors,  or  in  children  by  convulsions  or  vomiting;  the 
gradual  onset  by  malaise,  shiveriness,  loss  of  appetite,  and 
headache.  Pneumonia  is  a  good  example  of  the  sudden 
onset,  and  typhoid  fever  of  the  gradual  onset,  of  fever. 

The  course  of  fever  characterizing  different  diseases 
varies  in  three  different  ways.  These  are  spoken  of  as  con- 
tinuous, intermittent,  and  remittent  fevers. 

In  continuous  fever  the  temperature  remains  at  about 
the  same  elevation,  with  little  variation  between  the  morn- 


DATE 


ME 


Fig.  35. — Temperature  chart  of  lobar  pneumonia  (Paul). 

ing  and  evening  temperatures.  The  temperature  in 
pneumonia  is  a  good  example  (Fig.  35). 

In  remittent  fever  the  highest  point  in  the  daily  tempera- 
ture is  followed  by  a  steady  fall  or  drop  of  two  or  more 
degrees.  The  lowest  point  of  the  temperature  is,  however, 
always  above  normal.  The  highest  temperature-point  in 
remittent  fever  is  usually  in  the  evening,  the  lowest  in  the 
morning.  Usually  the  temperature  in  typhoid  fever  runs 
such  a  course  (Fig.  36). 

In  intermittent  fever  the  temperature,  having  mounted 
steadily  to  its  highest  point,  falls  again  to  normal  or  sub- 


198      TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 

normal.     The  rise  of  temperature  followed  by  the  remis- 
sion may  occur  daily  (usually  at  the  same  hour)  or  after  a 


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Fig.  36. — Temperature-curve  in  a  typic  case  of  typhoid  fever 
(Register). 

lapse  of  a  regular  number  of  days.  Intermittent  fever  is 
characteristic  of  the  common  forms  of  malarial  fever  and 
of  long-continued  septic  conditions,  such  as  the  later  stages 


Fig.  37.— Temperature  chart  of  intermittent  malaria  (tertian)  (Paul). 

of   pulmonary    tuberculosis.     The    rise    of   temperature 
is  in  the  nature  of  a  sudden  onset,  and  the  fall,  of  a  crisis. 


TEMPERATURE 


199 


The  usual  physical  manifestations  accompanying  the  sud- 
den onset  and  the  crisis  are  commonly  present  (Fig.  37). 

Prolonged  conditions  of  intermittent  fever  are  frequently 
described  as  hectic  fevers.  There  is  usually  an  enormous 
discrepancy  between  the  morning  and  evening  temperature, 
the  fall  in  the  temperature  being  accompanied  by  profuse 
sweating.  The  condition  is  most  frequently  seen  in  cases 
of  prolonged  suppuration,  such  as  the  later  stages  of  pul- 
monary tuberculosis  (Fig.  38). 


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Days  of  Fever. 
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Fig.  38. — Hectic  fever  in  phthisis  (Sahli  and  Potter). 


Diseases  accompanied  by  a  characteristic  rise  of  tem- 
perature are  roughly  classed  together  as  fevers.  Besides 
the  onset  or  invasion  period,  where  the  temperature  rises, 
and  the  decline,  where  the  temperature  falls,  either  by 
crisis  or  by  lysis,  there  is  an  intermediary  period  when 
the  temperature  remains  raised  for  a  certain  time.  This 
is  known  as  the  fastigium  or  the  stadium.  During  the 
fastigium  period  all  the  physical  manifestations  character- 
istic of  the  special  fever  are  intensified. 


200      TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 

Clinical  Thermometer. — The  temperature  of  the  body 
is  ascertained  by  the  clinical  thermometer.  This  is  the 
same  as  the  ordinary  atmospheric  thermometer,  with, 
for  the  sake  of  convenience,  only  those  degrees,  usually 
from  95°  to  110°  F.,  possible  to  the  body  temperature, 


Fig.  39. — Clinical  thermometer  (Pyle's  Personal  Hygiene). 

indicated.  The  scale  is  larger,  the  lines  between  the 
degrees  being  marked  off  into  fifths,  for  a  greater  minute- 
ness of  record. 

The  Fahrenheit,  Centigrade,  and  Reaumur  Scales  Com- 
pared.— In  America,  Great  Britain,  and  the  British  col- 
onies the  Fahrenheit  scale  is  exclusively  used.  It  is  said 
to  have  been  preferred  first  by  the  army  surgeons,  who,  in 
reading  daily  reports,  found  it  a  convenience  that  all 
fever  temperatures  were  recorded  by  three  figures,  thus 
quickly  catching  the  eye  in  long  lists  of  names.  On  the 
continent  of  Europe  the  Centigrade  scale  is  used,  and  in 
Switzerland  the  Reaumur  thermometer  may  be  met  with. 

In  comparing  these  scales  it  must  be  remembered  that 
while  in  the  Centigrade  and  Reaumur  scales  freezing- 
point  is  at  zero,  in  Fahrenheit  it  is  placed  at  32°;  there  is, 
therefore,  an  initial  difference  of  32°  between  the  Fahren- 
heit scale  and  that  of  either  of  the  other  two.  Further, 
there  is  a  difference  in  the  actual  value  of  the  degrees,  a 
whole  degree  Fahrenheit  equaling  only  f  the  degree  Centi- 
grade and  |  the  degree  Reaumur.  Bearing  these  points  in 
mind,  the  conversion  from  one  scale  to  another  is  very 
simple. 

To  convert  Fahrenheit  to  the  Centigrade  scale,  32  is  first 
subtracted  from  the  degree  Fahrenheit,  and  the  remainder 
is  multiplied  by  f.  To  convert  the  Centigrade  scale  to 
Fahrenheit,  the  degree  Centigrade  is  multiplied  by  •§•  and 
32  is  added  to  the  sum. 

Examples : 

C.  40°       40  X  |  =  72       72  +  32  =  104—104°  F. 

F.  100'4°  100'4  -  32  =  68'4    68'4  X  |  =  38—38°  C. 


TEMPERATURE  201 

For  the  Reaumur  scale  4  is  substituted  for  5,  otherwise 
the  calculation  is  the  same. 

In  taking  the  temperature  the  thermometer  may  be 
placed  under  the  tongue  with  the  lips  closed  for  five  min- 
utes, under  the  axilla  or  in  the  groin  for  ten  minutes,  or  in 
the  rectum  for  three  minutes. 

The  mouth  is  usually  the  most  convenient  place  for 
taking  the  temperature.  It  cannot,  however,  be  used 
with  very  young  children,  where  the  patient  is  delirious, 
where  local  inflammations  are  present,  or  where,  after 
certain  operations  or  from  extreme  weakness,  the  mouth 
cannot  be  closed,  nor  should  it  be  used  immediately  after 
eating  or  drinking. 

Where  the  axilla  is  used,  it  should  be  wiped  free  from 
perspiration  and  converted  into  a  closed  cavity  by  crossing 
the  arm  over  the  chest,  the  fingers  grasping  the  opposite 
shoulder.  If  the  thermometer  is  placed  in  the  groin,  the 
area  should  be  dry,  and  the  thigh  flexed  and  held  against 
the  abdominal  wall. 

The  rectal  temperature  is  best  for  infants,  young  chil- 
dren, and  restless  or  delirious  patients.  The  thermometer 
is  oiled  and  inserted  for  about  two  inches,  and  held  in 
place  by  a  piece  of  cotton  or  a  towel.  This  method  cannot 
be  employed  after  rectal  operations  or  where  there  is 
disease  or  local  inflammation  of  the  rectum.  It  should 
not  be  employed  where  diarrhea  is  present,  or  where  the 
rectum  contains  feces. 

The  temperature  in  the  mouth  is  usually  about  half  a 
degree  higher  than  that  of  the  axilla,  and  the  temperature 
in  the  rectum  again  half  a  degree  higher  than  that  in  the 
mouth. 

A  further  method  employed  sometimes  where  absolutely 
accurate  record  is  essential,  as  in  collecting  statistics, 
and  otherwise  impossible,  is  to  have  the  urine  voided  over 
the  bulb  of  the  thermometer,  the  urine  in  passing  being  at 
the  bodily  temperature. 

The  thermometer  must  be  washed  in  cold  water  after 
using,  and  kept  in  an  antiseptic  solution,  from  which  it  is 
rinsed  in  cold  water  and  wiped  dry  before  using  again.  It 
should  be  as  scrupulously  clean  as  a  glass  or  a  spoon. 


202      TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 

Those  used  for  rectal  temperatures  should  be  marked  and 
kept  apart  from  other  thermometers.  For  hospital 
use  a  practical  means  of  insuring  care  in  this  respect  is  to 
use  as  rectal  thermometers  those  made  with  the  bulbs  of 
colored  glass.  These  may  be  procured  from  A.  Bayer  and 
Son,  66  Beekman  St.,  New  York.  The  colored  bulbs  are 
also  a  convenience  where  a  thermometer  has  to  be  kept 
strictly  for  one  patient,  as  in  an  infectious  case. 

PULSE 

By  the  term  pulse  we  understand  the  beat  or  impulse 
that  is  felt  on  the  expansion  of  an  artery;  it  is  produced 
by  the  systole,  or  contraction  of  the  left  ventricle  of  the 
heart.  The  condition  of  the  pulse  is  an  indication  of  the 
state  of  the  circulation,  and  the  condition,  to  a  large  ex- 
tent, of  the  heart  and  blood-vessels.  Of  any  one  symptom, 
the  pulse  is  probably  the  most  important  indication  of  the 
physical  condition  of  the  patient. 

The  arteries  most  conveniently  used  for  taking  or  exam- 
ining the  pulse  are  those  lying  near  the  surface  of  the  body 
and  immediately  over  a  bone,  against  which  the  artery 
can  be  compressed.  That  most  often  used  is  at  the  wrist, 
where  the  radial  artery  can  be  felt  lying  over  the  radius  on 
the  inner  surface  of  the  thumb  side  of  the  wrist.  The 
femoral  artery  may  be  easily  felt  in  the  groin,  where  it 
slips  over  the  rim  of  the  pelvis.  The  temporal  artery  is 
felt  against  the  bony  prominence  immediately  in  front  of 
the  external  opening  of  the  ear,  and  the  facial  artery  on 
the  edge  of  the  lower  jaw,  usually  on  a  line  with  the  corner 
of  the  mouth.  The  femoral  artery  may  frequently  be  felt 
when  no  pulse  can  be  detected  at  the  wrist,  owing  to  the 
larger  size  of  the  vessel  and  its  location  nearer  the  heart. 
The  common  carotid  arteries  on  either  side  of  the  throat, 
although  not  lying  over  a  bone,  are  valuable,  as  in  cases 
of  profound  prostration  the  pulse  may  be  felt  in  them  after 
it  has  become  imperceptible  at  points  more  remote  from 
the  heart. 

Taking  the  Pulse. — The  pulse  is  taken  by  placing  two 
or  three  fingers  steadily  over  the  artery  for  not  less  than 
one  minute,  and  alternately  making  and  relaxing  a  mod- 


PULSE  203 

crate  pressure  against  the  underlying  bone.  The  body 
should  be  at  rest  at  the  time,  and  the  arm,  if  it  is  the  radial 
pulse,  recumbent.  An  excitable  patient  should  have  his 
attention  diverted  and  the  examination  be  made  for  a 
longer  period.  The  examination  of  the  pulse  should 
ascertain : 

First:  Condition  of  the  artery. 

Second:  Amount  of  tension. 

Third :  Volume  of  the  pulse. 

Fourth:  The  number  of  beats  to  the  minute. 

Fifth:  Their  character,  regularity,  and  irregularity. 

In  a  normal  pulse  the  artery  should  feel  firm,  round,  and 
elastic,  the  blood-stream  should  fill  it  with  moderate 
force,  and  the  beat  still  be  perceptible  under  moderate 
pressure  from  the  fingers.  There  should  be  about  72 
beats  to  the  minute  of  perfect  rhythm  and  regularity. 

Instead  of  feeling  firm  and  elastic,  the  arterial  walls 
may  be  found  hard  and  unyielding,  twisted,  and  giving 
the  impression  of  brittleness.  To  some  extent  this  occurs 
normally  in  old  age.  It  indicates*  a  condition  of  arterial 
degeneration  known  as  arteriosclerosis.  This  condition 
is  also  found  as  a  result  of  disease,  such  as  Bright's  disease, 
etc.,  and  is  an  important  symptom. 

Tension  is  caused  by  the  resistance  of  arterial  walls  to 
the  blood-pressure.  By  the  degree  of  tension  the  force  of 
the  blood-pressure  is  estimated.  Tension  is  said  to  be 
high  when  the  artery  remains  distended  between  the  pulse- 
beats,  and  low  when  between  the  beats  it  feels  empty  and 
is  easily  compressed.  Tension  may  be  altered  by  the  size 
of  the  blood-stream,  as  after  loss  of  blood  from  hemorrhage, 
by  changes  in  the  regularity  or  force  of  the  heart's  action, 
as  in  some  forms  of  heart  disease,  and  by  changes  in  the 
arterial  walls,  affecting  their  elasticity.  From  the  latter 
condition  a  high-tension  pulse  is  found  in  those  forms  of 
chronic  disease  associated  with  arteriosclerosis. 

A  low-tension  pulse  is  characteristic  of  conditions  of  low 
vitality,  such  as  collapse,  or  the  prostration  occurring  at 
the  close  of  a  long  illness,  such  as  typhoid  fever. 

Drugs  which  strengthen  the  condition  of  the  heart  raise 
the  tension  of  the  arteries,  such,  for  example,  as  digitalis 


204      TEMPERATURE. — PULSE. — RESPIRATION.— CHARTS 

The  tension  of  a  pulse  may  be  lowered  either  by  drugs 
such  as  nitrate  of  amyl  and  nitroglycerin,  which  reduce 
tension  by  dilating  the  blood-vessels,  or  by  drugs  which 
act  as  sedatives  to  the  heart,  of  which  aconite  is  an  ex- 
ample. The  tension  of  a  pulse  is  estimated  by  the  amount 
of  pressure  necessary  to  obliterate  the  beat. 

Sphygmomanometer. — A  special  instrument  for  estima- 
ting the  blood-pressure  is  known  as  a  sphygmomanometer, 
of  which  there  are  several  varieties. 


Fig.  40. — Technio  of  sphygmomanometry  with  the  Stanton  instru- 
ment (Morrow). 

The  instrument  in  general  use  at  the  present  day  consists 
of  three  parts :  a  dial  with  a  mercury  column  like  an  atmo- 
spheric thermometer,  the  scale  marked  out  in  millimeters 
(a),  a  wide  pneumatic  cuff  (6),  and  an  air  pump  consisting 
of  a  double  rubber  bulb,  the  first  (c)  the  pump,  the 
second  bulb  (d)  acting  as  an  air-reservoir  to  equalize  the 
air-pressure,  and  protected  from  overexpansion  by  a  silk 
netting.  The  three  pieces  are  connected  together  by 
tubing,  so  that  when  air  is  introduced  by  the  pump,  it  is 
at  the  same  pressure  in  every  part  of  the  apparatus. 


PULSE  205 

The  cuff,  the  inner  surface  of  which  is  an  air-bag,  is 
secured  round  the  upper  arm  and  inflated  until  the  pres- 
sure so  produced  on  the  brachial  artery  causes  obliteration 
of  the  pulse  at  the  wrist;  at  the  same  time  the  column  of 
mercury  is  also  raised  by  the  air-pressure,  and  the  amount 
of  pressure  necessary  to  obliterate  the  radial  pulse  can  be 
read  off  on  the  scale  in  millimeters. 

In  "  taking  "  the  blood-pressure  the  fingers  are  kept  on 
the  radial  pulse,  while  the  air  is  pumped  simultaneously 
into  the  cuff  and  the  mercury  chamber.  When  the  pulse 
is  obliterated,  air  is  very  gently  allowed  to  escape,  keeping 
the  finger  on  the  wrist  and  watching  the  column  of  mer- 
cury closely.  On  the  first  faint  sensation  of  pulse  under  the 
finger,  the  height  of  the  mercury  is  noted  and  is  taken  as 
the  estimate  of  the  blood-pressure. 

The  average  blood-pressure  in  a  healthy  adult  is  be- 
tween 120  and  140;  it  is  lower  in  children  and  higher  with 
increasing  age.  In  diseases  associated  with  high  blood- 
pressure  it  may  rise  to  between  200  and  300. 

The  instrument  is  valued  as  a  more  accurate  means 
of  gaging  the  blood-pressure  than  merely  "taking"  the 
pulse  with  the  finger,  especially  in  conditions  where  the 
1  >lood-pressure  may  be  subject  to  frequent  and  abrupt 
changes. 

A  pulse  of  high  tension  may  be  described  as  hard  and 
resistant,  a  low-tension  pulse  as  soft,  or  compressible. 

The  volume  or  size  of  the  pulse  is  greater  at  the  onset 
of  fevers,  in  threatened  apoplexy,  heat-stroke,  and  other 
conditions  usually  associated  with  rise  of  temperature;  and 
less  in  conditions  of  lowered  vitality  and  great  prostration. 
Where  the  volume  is  great,  the  pulse  is  spoken  of  as  full; 
if  at  the  same  time  accompanied  by  increased  frequency  of 
beat,  it  is  sometimes  described  as  full  and  bounding. 
This  type  is  common  at  the  beginning  of  feverish  condi- 
tions. A  pulse  of  lower  than  the  usual  volume  is  called 
a  small  pulse.  After  severe  hemorrhage  and  in  conditions 
of  collapse  it  may  be  so  small  as  to  be  almost  imperceptible, 
the  artery  feeling  like  a  little  thread  under  the  examining 
finger;  such  a  pulse  is  known  as  a  thready  pulse.  The 
tension  of  a  pulse  may  be  low,  while  the  volume  is  large 


206      TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 

and  vice  versa.  A  hard  pulse  of  very  small  volume  is 
described  as  wiry. 

The  number  of  beats  to  the  minute  in  a  normal  pulse  is 
about  72.  It  varies,  however,  with  age,  sex,  and  idiosyn- 
crasy. In  a  new-born  baby  the  number  is  from  120  to  140 
a  minute;  in  young  children  below  the  eighth  year,  between 
90  and  100;  from  the  eighth  to  the  fourteenth  year,  be- 
tween 80  and  90,  while  in  old  age  the  pulse  is  usually  below 
normal.  In  young  children  there  is  no  difference  between 
the  pulse-rate  of  the  sexes;  in  adult  life  a  woman's  pulse- 
rate  is  perceptibly  higher  than  that  of  a  man.  Persons 
may  be  met  with  in  whom,  in  an  otherwise  normal  con- 
dition of  health,  the  pulse-rate  is  abnormally  quick  or  ab- 
normally slow. 

In  health  the  pulse  is  accelerated  by  exercise,  excitement, 
emotion,  eating,  the  action  of  drugs  which  stimulate  the 
heart,  such  as  strychnin  and  atropin,  and  by  small  doses  of 
alcohol.  It  is  slower  during  repose  and  sleep,  and  in  conse- 
quence of  fatigue,  exposure,  or  fasting.  These  conditions 
should  be  borne  in  mind  in  examining  the  pulse.  Drugs 
which  either  quiet  or  strengthen  the  heart  reduce  the 
pulse-rate — such  drugs,  for  example,  as  aconite  and  digi- 
talis. An  attempt  to  give  a  table  of  conditions  stating  the 
diseases  in  which  the  pulse-rate  is  high  or  low  would  be 
misleading.  It  would  be  difficult  to  make  it  sufficiently 
complete  to  be  of  value,  and  it  must  be  remembered  that 
in  diseases  the  same  conditions  may  be  found  that  affect 
the  pulse  in  health,  and  will  have  the  same  effect  to  a 
greater  extent,  the  body  being  in  a  more  susceptible  con- 
dition. 

Varieties  of  Pulse. — As  a  rule,  the  pulse  rises  with  the 
bodily  temperature  at  the  rate  of  ten  beats  of  pulse  to  one 
degree  of  temperature,  though  exceptions  are  often  noted 
in  diseases,  such,  for  example,  as  typhoid  fever,  where  the 
pulse  is  low  in  proportion  to  the  temperature,  or  in  scarlet 
fever,  where  the  pulse  is  disproportionately  high.  We 
notice  an  increased  frequency  of  pulse  in  all  acute  diseases, 
in  almost  all  forms  of  valvular  heart  disease,  in  exophthal- 
mic goiter,  in  many  disorders  of  the  nervous  system,  in 
reaction  from  conditions  of  lowered  vitality,  such  as  shock, 


PULSE  207 

etc.,  and  frequently  on  approaching  death.  We  find  a 
slow  pulse  generally  where  we  find  a  lowered  vitality,  as 
in  the  convalescence  following  acute  diseases,  after  severe 
hemorrhages,  in  many  conditions  of  chronic  diseases,  and 
in  depressed  mental  conditions.  A  slow  pulse  is  usual  in 
jaundice  and  in  diseases  of  accidents  causing  pressure  at 
the  base  of  the  brain. 

The  condition  of  persistent  increased  rate  of  the  pulse 
is  termed  tachycardia  (quick  heart) ;  the  condition  of  per- 
sistent infrequency  is  known  as  bradycardia  (slow  heart). 
The  pulse  is  said  to  be  slow  where  the  number  of  beats 
is  considerably  below  normal;  quick  or  frequent,  where 
the  pulse  runs  from  100  to  120;  rapid,  from  120  to  160, 
above  which  it  is  very  difficult  to  count,  and  is  spoken 
of  as  running.  The  terms  quick  and  frequent  are  loosely 
employed  in  this  way.  Accurately,  quick  should  be  em- 
ployed where  the  beat  occupies  a  shorter  time  than  usual; 
frequent,  where  the  number  of  beats  is  greater  in  a  given 
time. 

Where  each  successive  beat  of  the  pulse  is  of  equal  value, 
the  pulse  is  said  to  be  regular.  The  regular  pulse,  as  a 
rule,  is  accepted  as  a  good  symptom. 

The  more  common  forms  of  irregularity  are  as  follows: 
The  most  common  deviation  from  regularity  is  an  inter- 
mission of  a  beat,  either  at  regular  or  irregular  intervals. 
While  occurring  in  many  diseases  due  to  organic  lesion, 
the  intermediate  pulse  may  also  accompany  causes  of 
trifling  significance,  such  as  fasting,  dyspepsia,  the  use  of 
tobacco,  and  may  frequently  be  observed  in  the  pulse  of 
young  children  or  of  aged  persons  during  sleep,  especially 
toward  morning,  possibly  caused  by  the  length  of  time  they 
have  been  without  food. 

In  the  irregular  pulse  the  pulsation  may  be  unequal  in 
time  and  in  character.  Some  beats  may  follow  each  other 
with  great  rapidity,  to  be  followed  by  slow  beats  and  by  a 
long  intermission;  at  the  same  time  the  pulsation  may  be 
of  varying  force  and  volume,  the  latter  condition  requiring 
more  experience  to  recognize  than  irregularity  of  time, 
which  is  easily  detected.  An  irregular  pulse  is  a  symptom 
of  serious  disease,  most  commonly  of  some  form  of  heart 


208      TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 

disease.  It  may  also  be  caused  by  an  overdose  of  certain 
drugs,  such,  for  example,  as  digitalis,  which  has  a  powerful 
effect  upon  the  action  of  the  heart. 

The  dicrotic  pulse  is  a  variation  from  the  normal  pulse 
frequently  met  with  in  conditions  of  prolonged  fever 
and  low  vitality,  such  as  typhoid  fever  or  septicemia. 
It  is  characterized  by  a  secondary  impulse  in  each  beat, 
following  the  first  as  a  small  wave  may  a  large  one.  It 
indicates  a  relaxed  condition  of  the  arteries.  The  primary 
beat  follows  the  systolic  contraction  of  the  ventricle;  the 
secondary  beat  occurs  after  the  closing  of  the  aortic  valves, 
and  is  a  transmission  of  the  impulse  given  to  the  blood- 
stream by  the  contraction  of  the  walls  of  the  aorta,  an 
impulse  which,  though  always  present,  is  imperceptible 
to  the  examining  finger  in  the  ordinary  condition  of  the 
circulation. 

Where  the  dicrotic  beat  is  strong,  it  is  possible  to  mistake 
it  for  a  second  true  beat;  when  any  doubt  exists,  the 
heart-beats  should  be  counted  at  the  same  time  the  pulse 
is  taken. 

Another  variety  of  pulse,  which  should  be  recognized 
when  met,  is  the  water-hammer  pulse,  also  known  as 
Corrigan's  pulse.  It  may  be  observed  in  the  carotids  as 
a  sharp  rising  and  falling  of  the  artery.  Under  the  finger 
it  has  the  sensation  of  a  sharp,  powerful  beat  with  a 
quick  recoil.  It  is  associated  with  disease  of  the  aortic 
valves,  producing  a  condition  known  as  aortic  regurgita- 
tion. 

In  persons  suffering  from  severe  anemia  the  pulse  may 
be  visible  in  the  capillaries.  In  order  to  observe  it  the 
mucous  membrane  of  the  lip  may  be  pressed  with  a  glass 
slide  until  colorless,  when  the  area  may  be  seen  under  the 
slide  to  flush  and  pale  rhythmically.  It  is  also  sometimes 
observed  under  the  finger-nails.  The  condition  is  seen, 
as  a  rule,  only  in  extreme  cases. 

In  some  rare  conditions  the  pulse  of  the  right  and  left 
wrist  on  the  same  individual  differ.  This  points  to  some 
obstruction  in  the  course  of  the  circulation  of  one  or  other 
upper  extremity;  generally  it  is  caused  by  pressure  from 
an  aortic  aneurysm. 


Pulsus  durus. 


Pulaus  mollis. 


Pulsus  dicroticus. 


Pulsus  anacroticus. 


Sphygmograms  of  pathologic  typos  of  tlie  arterial  pulse.     (Tracings 
by  Dr.  G.  Bachmann.)     (From  DaCosta's  "  Physical  Diagnosis.") 


RESPIRATION  209 

The  Sphygmograph. — This  is  an  instrument  for  record- 
ing graphically  the  different  variations  of  the  pulse.  It 
is  somewhat  complicated.  It  consists  essentially  of  a 
metal  plate,  fixed  by  a  strap  round  the  wrist  over  the 
pulsating  artery.  To  the  plate  is  attached  a  delicately 
adjusted  needle  in  such  a  manner  that  the  pulsations  of 
the  artery  are  transmitted  to  the  needle  and  traced  by 
the  needle  on  specially  prepared  black  paper  as  a  fine, 
white,  wave-like  line,  corresponding  exactly  to  the  dila- 
tation and  contraction  of  the  walls  of  the  vessel.  These 
traceries  are  known  as  sphygmograms,  and  offer  a  perfect 
picture  of  the  pulse-wave.  In  a  normal  pulse  the  secondary 
impulse,  noted  above,  is  shown  as  a  notch  in  the  descend- 
ing line;  where  the  pulse  is  dicrotic,  the  notch  becomes 
a  well-marked  second  wave,  often  only  slightly  smaller 
than  the  primary  wave.  Many  irregularities,  difficult 
to  observe  with  the  examining  finger,  are  clearly  shown  and 
easily  studied  when  traced  as  a  sphygmogram  (Plate  II). 

RESPIRATION 

Of  equal  importance  with  the  observation  of  the  rate 
of  the  temperature  and  the  pulse  is  the  observation  of  the 
rate  and  character  of  respiration;  that  is  to  say,  the 
manner  in  which  breathing  is  performed. 

The  immense  importance  of  breathing  is  realized  on 
calling  to  mind  that,  through  the  act  of  respiration,  the 
body  is  supplied  with  oxygen,  without  which  life  cannot 
be  maintained  even  for  a  few  moments,  and  that  with  the 
act  of  respiration  the  body  parts  with  carbonic  acid  gas, 
a  poison  which,  if  retained,  would  be  fatal  to  life.  Any 
interference  with  the  normal  respiration  is  likely,  there- 
fore, to  have  serious  results. 

Breathing  under  normal  conditions  is  an  involuntary  act, 
accomplished  without  exertion,  sound,  or  pain,  and  ac- 
companied with  a  rhythmic  rising  and  falling  of  the  chest- 
walls  and  the  walls  of  the  abdomen,  due  to  the  expansion 
and  contraction  of  the  muscles  of  respiration.  In  the 
act  of  respiration  the  lungs  are  passive,  their  part  being 
to  afford  an  enormous  surface,  where  the  fine  capillary 
btood-vessels  can  ramify,  and  be  brought  into  direct  con- 

14 


210      TEMPER  AT  URE. — PULSE. — RESPIRATION. — CHARTS 

tact  with  the  air  of  the  atmosphere.  The  membrane  of 
which  they  are  constructed  is  so  delicate  that  it  is  easily 
permeable  to  oxygen  and  carbonic  acid  gas,  as  are  also 
the  walls  of  the  capillary  blood-vessels.  Air  is  drawn  into 
the  lungs  by  the  mechanical  enlargement  of  the  cavity  of 
the  chest,  just  as  a  pair  of  bellows  is  inflated  with  air  by 
pulling  the  surfaces  apart ;  when  the  cavity  is  made  smaller 
again,  the  air  is  expelled.  The  muscles  of  respiration  are 
the  intercostal  muscles,  which  alternately  elevate  and  de- 
press the  ribs,  and  the  diaphragm,  which  forms  the  floor 
of  the  chest  cavity.  In  emergencies  they  are  assisted  by 
the  muscles  of  the  abdominal  wall  and  by  others.  The 
mechanical  act  of  respiration  is  controlled  by  nervous  im- 
pulse, of  which  the  center  is  situated  in  the  medulla  ob- 
longata,  often  called,  from  the  important  nerve-centers 
there  situated,  the  vital  knot.  The  nerve-center  is  stim- 
ulated by  the  need  of  the  body  for  oxygen. 

Normal  respiration  demands  a  proper  balance  between 
the  amount  and  quality  of  the  air  that  reaches  the  lungs 
and  the  amount  and  quality  of  the  blood  circulating  in  the 
lungs.  The  balance  may  be  affected  by  the  changes  in 
the  atmosphere,  as,  for  example,  when  the  atmospheric 
air  is  deficient  in  oxygen;  by  alterations  in  the  condition 
of  the  blood  or  in  the  circulation,  as  in  anemia  or  heart 
disease;  by  obstructions  in  the  lungs  or  air-passages,  either 
from  foreign  bodies  or  from  the  inflammatory  processes 
of  disease;  and  by  interference  with  the  mechanism  of 
respiration.  The  latter  may  be  caused  by  paralysis  of 
the  muscles  of  the  chest-wall,  by  rigidity  of  the  abdominal 
walls,  as  in  peritonitis,  or  by  the  pressure  of  fluid  or 
a  tumor  from  neighboring  structures.  In  all  these  con- 
ditions we  get  the  character  and  rate  of  respiration  al- 
tered, and  breathing,  an  act  attained  by  effort,  sound,  and 
pain  or  discomfort.  At  the  same  time  every  part  of  the 
body  will  also  suffer  from  the  deficiency  of  oxygen,  and  the 
poisonous  effects  of  the  carbonic  acid  gas,  which  has  not 
been  eliminated  by  contact  with  the  oxygen. 

The  act  of  respiration  is  also  altered  by  conditions 
directly  affecting  the  respiratory  centers,  such  as  toxic 
conditions  of  the  system  and  the  action  of  certain  drugs. 


RESPIRATION  211 

The  rate  of  respiration  may  be  determined  by  counting 
the  number  of  respirations  in  the  minute.  The  average 
normal  rate  of  respiration  a  minute  in  the  human  being 
is  reckoned  as  follows: 

16-18  in  the  male  adult. 
18-20  in  the  female  adult. 
20-25  in  young  children. 
30-35  in  infants. 

The  ratio  between  respiration  and  pulse  is  commonly 
1  in  4.  In  health  respiration  may  be  quickened  by  exer- 
tion, excitement,  emotion,  and  by  sudden  chilling  of  the 
surface  of  the  body,  as  in  cold  bathing.  It  is  slower  in 
repose,  during  sleep,  and  from  the  effects  of  fatigue. 

The  rate  of  respiration  is  increased  in  all  diseases  of  the 
lungs  and  air-passages;  usually  in  feverish  conditions, 
in  diseases  due  to  toxins,  such  as  the  infectious  fevers, 
uremia,  etc.;  in  organic  diseases  affecting  the  circulation, 
such  as  heart  disease  and  nephritis;  in  disorders  in  which 
the  composition  of  the  blood  is  altered,  such  as  anemia; 
and  in  conditions  where  obstruction  to  the  mechanism 
of  respiration  exists,  as  mentioned  above.  Respiration 
is  also  quickened  by  the  action  of  drugs  that  stimulate 
the  respiratory  centers,  of  which  atropin,  the  alkaloid 
of  belladonna,  is  the  most  powerful  known. 

The  rate  of  respiration  is  decreased  in  many  conditions 
of  injury  to  and  disease  of  the  brain,  in  most  forms  of 
coma,  and  from  the  action  of  those  drugs  that  depress  the 
respiratory  centers,  such  as  opium.  Very  slow  respira- 
tion is  the  most  important  symptom  in  opium-poisoning. 

Character  of  Respiration. — The  respiration  is  described 
as  shallow,  when  the  volume  of  inspired  and  expired  air  is 
less  than  usual;  deep,  when  it  is  greater  than  usual.  Shal- 
low respirations  may  accompany  either  rapid  or  slow  res- 
pirations, though  more  usually  the  former.  They  may 
1)0  caused  by  rigidity  of  the  abdomen,  as  in  peritonitis 
or  abdominal  distention;  by  pressure  on  the  diaphragm 
from  fluid,  etc.,  or  by  a  decrease  in  the  available  area  of 
lung  surface,  as  from  inflammatory  processes,  consolida- 
tion, etc.  Shallow  respirations  are  also  common  in  con- 


212      TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 

ditions  of  profound  prostration,  where  the  vital  centers  are 
greatly  depressed. 

Deep  respirations  are  characteristic  of  many  diseases  of 
the  brain,  and  especially  of  those  conditions  in  which, 
either  from  disease  or  injury,  there  is  compression  of  the 
brain. 

Dyspnea  means  difficult  breathing,  and  is  a  term  used 
when  the  act  of  breathing  is  accompanied  by  conscious 
effort.  It  is  not  necessarily  associated  with  pain,  though 
such  is  frequently  the  case.  Dyspnea  occurs  whenever 
respiration  is  obstructed  by  any  of  the  conditions  men- 
tioned above.  Where  dyspnea  is  so  great  that  breathing 
is  possible  only  in  an  upright  position,  the  term  orthopnea, 
upright  breathing,  is  used  to  describe  the  condition. 
Pain  associated  with  dyspnea  is  most  marked  where  the 
act  of  breathing  causes  friction  between  sensitive  surfaces, 
as,  for  example,  in  pleurisy,  where  pain  in  the  side,  in- 
creased by  drawing  a  long  breath,  is  a  prominent  symptom. 
The  pain  is  due  to  the  rubbing  together  of  the  inflamed 
surfaces  of  the  pleura,  the  double  covering  that  envelops 
each  lung. 

Dyspnea  is  usually  accompanied  by  sound.  In  certain 
diseases  the  sound  is  so  characteristic  as  to  be  diagnostic. 
Thus  we  have  the  crowing  inspiration  of  croup,  the  harsh 
or  stridulent  breathing  of  diphtheria,  the  wheezing  of  bron- 
chial affections,  the  grunting  expirations  of  pneumonia; 
where  the  obstruction  to  respiration  is  great,  and  where, 
as  in  cases  of  great  prostration,  the  body  is  not  getting  the 
oxygen  it  needs,  the  respirations  may  become  irregular 
and  jerky. 

Where  the  act  of  inspiration  is  accompanied  by  a  loud, 
snoring  noise,  the  breathing  is  said  to  be  stertorous.  It 
is  noticed  in  many  forms  of  coma,  especially  in  that  of 
apoplexy,  and  is  caused  by  the  vibrations  of  the  relaxed 
soft  palate.  Sighing  and  yawning  in  the  course  of  an 
illness  are  frequently  significant.  Sighing  is  a  common 
symptom  in  severe  hemorrhages,  and  indicates  that  the 
body  is  not  receiving  sufficient  oxygen;  it  is  often  accom- 
panied by  gasping  and  fighting  for  air,  a  condition  known 
as  air-hunger.  Yawning  is  a  symptom  of  syncope  or 


RESPIRATION  213 

faintness  when  occurring  in  conditions  of  shock,  collapse, 
or  hemorrhage;  it  is,  on  the  other  hand,  considered  as  a 
favorable  symptom  and  a  sign  of  returning  vigor  if  noticed 
during  convalescence  after  a  long  illness. 

A  type  of  respiration  known  as  tidal  breathing,  or 
Cheyne-Stokes  respiration,  is  sometimes  observed  in  very 
serious  physical  conditions.  In  a  typical  case  the  respira- 
tions begin  quietly;  each  succeeding  respiration  is  a  little 
louder  and  deeper  than  the  preceding  one,  until  a  climax 
is  reached,  after  which  the  respirations  as  gradually  sub- 
side; the  wave  of  breathing  is  followed  by  a  complete 
pause  of  several  moments'  duration,  following  which  the 
same  process  is  repeated.  Such  breathing  indicates  fail- 
ure of  the  respiratory  centers,  but  how  it  is  caused  is  not 
fully  understood.  It  is  always  of  grave  significance,  and 
in  the  course  of  acute  illness  is  usually  regarded  as  a  sign 
of  approaching  death.  It  must  not  be  confounded  with 
irregular  respirations,  of  varying  rate  and  force,  which  do 
not  occur  rhythmically,  and  which  are  not  followed  by  a 
distinct  pause. 

Mechanism. — Together  with  the  rate  and  character  of 
respirations  the  pupil  should  be  taught  to  observe  certain 
physical  conditions  which  accompany  the  mechanical  act 
of  breathing.  This  will  include  observation  of  the  shape 
of  the  chest,  of  the  action  of  the  muscles  of  respiration,  and 
of  the  positions  assumed  by  the  patient. 

In  observing  the  mechanism  of  respiration  it  will  be 
noticed  that  women  have  a  tendency  to  use  chiefly  the 
chest  muscles  (thoracic  breathing),  and  men  and  children 
chiefly  the  diaphragm  and  abdominal  muscles  (abdominal 
breathing).  The  use  of  deep  breathing  exercises  aims  at 
modifying  this  tendency. 

In  disease,  the  area  used  in  the  mechanism  of  breathing 
may  be  greatly  modified,  the  greater  part  of  the  work  being 
thrown  on  the  unaffected  areas;  thus,  when  the  action  of 
the  abdominal  muscles  causes  pain,  as  in  peritonitis,  or 
their  action  is  impeded,  as  by  pressure  from  a  tumor  or 
the  presence  of  fluid  or  gas  in  the  abdominal  cavity,  we 
get  the  thoracic  muscles  only  working — a  condition  spoken 
of  as  restricted  abdominal  breathing.  In  pleurisy  and  in 


214      TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 

diseases  causing  temporary  or  permanent  consolidation  of 
the  lungs  the  affected  side  of  the  chest  is  noticed  to  expand 
less  than  the  sound  side.  Where  the  bases  of  the  lungs, 
for  example,  are  solid,  the  upper  part  of  the  chest  will 
do  practically  all  the  work,  as  in  cases  of  emphysema. 
The  term  used  for  this  condition  is  diminished  expansion. 
In  new-born  infants  it  may  sometimes  be  observed  that 
one  side  of  the  chest-wall  has  failed  altogether  to  expand, 
a  serious  condition,  requiring  resort  to  artificial  respira- 
tion to  rectify  it. 

The  position  of  the  patient  with  reference  to  his  breath- 
ing is  frequently  significant  of  disease.  In  diseases  of 
the  lungs  patients  have  a  tendency  to  lie  on  the  affected 
side,  thus  giving  the  sound  lung  free  play.  Where 
obstruction  exists  in  the  air-passages,  such  as  from  asthma, 
patients  cannot  breathe  in  the  recumbent  position,  and 
the  same  condition  is  observed  in  those  forms  of  heart 
disease  associated  with  venous  congestion. 

Where  there  is  prolonged  dyspnea  from  any  cause, 
the  ordinary  muscles  of  respiration  become  inadequate  for 
the  work.  To  aid  in  overcoming  this  obstruction  other 
muscles  must  be  brought  into  play.  The  first  to  be 
observed  will  be  the  sternocleidomastoids,  the  muscles 
lying  on  either  side  of  the  throat,  which  have  their  origin 
in  the  clavicle  and  sternum  and  their  insertion  in  the 
mastoid  bone.  By  their  action  the  upper  part  of  the 
sternum  and  clavicle  are  brought  forward  and  upward, 
thus  aiding  in  enlarging  the  thoracic  cavity.  Next,  the 
tiny  muscles  of  the  alae,  or  wings  of  the  nostril,  will  be 
noticed  enlarging,  to  a  slight  extent,  by  their  dilatation, 
the  openings  to  the  air-passages.  When  the  effort  of 
respiration  is  very  great,  the  lower  end  of  the  sternum  may 
be  seen  to  be  sucked  in  with  each  inspiration,  forming 
an  appreciable  hollow  in  the  chest  at  this  point.  These 
symptoms  are  of  serious  significance. 

As  a  patient  gets  very  weak  the  action  of  the  sterno- 
cleidomastoid  muscles  has  a  tendency  to  draw  the  head 
backward,  throwing  the  chin  forward  and  upward  with 
each  inspiration,  and  giving  to  the  head  a  rocking  move- 
ment. This  is  usually  a  sign  of  swiftly  approaching  death, 


RESPIRATION  215 

and  is  almost  invariably  present  some  minutes  before  death 
occurs. 

The  rosy  color  of  the  skin  is  dependent  upon  the  oxy- 
gen taken  up  by  the  blood.  An  examination  of  the  pa- 
tient's skin  will,  therefore,  show  very  quickly  if  respiration 
is  failing  to  give  the  blood  a  sufficient  supply  of  oxygen. 
Blood  deficient  in  oxygen  has  a  dark  bluish  hue.  This 
discoloration  will  first  be  noticed  about  the  lips;  in  other 
words,  they  become  blue  or  cyanosed.  In  severe  cases 
the  cyanosis  will  spread  to  the  extremities  and  be  noticed 
at  the  tips  of  the  fingers,  under  the  nails,  and  may  finally 
extend  to  the  whole  body. 

It  will  readily  be  seen  that  a  record  of  the  character  of 
the  respiration  will  hardly  be  complete  without  an  intelli- 
gent observation  of  the  above  conditions. 

As  a  record  of  the  pulse  and  respiration  can  be  achieved 
with  very  little,  if  any,  disturbance  to  the  patient,  they 
can  be  made  more  frequently  than  that  of  the  temperature, 
the  taking  of  which  in  many  instances  is  fatiguing,  and 
sometimes  impracticable.  Conditions  calling  for  frequent 
observations  of  the  pulse  and  respiration  are — during 
and  following  the  administration  of  an  anesthetic;  in 
cases  of  shock,  collapse,  or  hemorrhage;  during  and  after 
a  crisis — circumstances  in  which,  it  is  obvious,  the  use  of 
the  temperature  thermometer  would  be  either  imprac- 
ticable or  inadvisable.  Where  a  record  of  the  temperature 
is  made,  however,  the  pulse  and  respiration  are  recorded 
at  the  same  time,  their  relation  to  each  other  being  of  great 
importance. 

In  counting  the  rate  of  respiration  in  nervous  patients 
it  is  advisable  to  do  so  without  their  knowledge.  In  many 
cases  the  respirations  can  be  counted  by  watching  the 
rise  and  fall  of  the  chest-wall.  As  it  is  impossible  to  main- 
tain any  but  the  natural  rate  of  breathing  for  any  length 
of  time,  a  little  patience  is  usually  all  that  is  necessary 
to  take  the  respirations  correctly.  Where  there  is  any 
doubt,  the  respirations  should  be  counted  while  the  patient 
is  asleep. 


216      TEMPERATURE. — PULSE. — RESPIRATION. — CHARTS 

CHARTS 

Clinical  charts  are  usually  found  more  convenient 
than  written  records  for  following  the  course  of  an  illness. 
A  picture  of  the  temperature  day  by  day  is  by  this  means 
given  at  a  glance,  and  if  desired,  the  pulse  and  respira- 
tion and  other  matters,  such  as  weight,  amount  of  urine, 
etc.,  can  be  recorded  in  the  same  way. 

The  rulings  on  the  temperature  chart  correspond 
exactly  to  the  markings  on  the  clinical  thermometer, 
with  a  broad  black  line  at  the  98.5°  of  the  normal  tempera- 
ture; cross  rulings  divide  the  chart  into  spaces,  which  may 
be  made  to  signify  days  or  portions  of  a  day,  as  desired. 
If  several  spaces  are  taken  for  one  day,  as  in  the  four- 
hourly  chart,  Fig.  41,  a  well-marked  ruled  line  should 
divide  the  days  between  the  last  temperature  taken  on 
one  date  and  the  first  after  midnight  on  the  following. 
A  dot  is  made  on  the  line  corresponding  to  the  height  of 
temperature  shown  by  the  clinical  thermometer,  and  the 
dots  connected  by  a  line  drawn  from  one  to  the  other. 
Besides  the  temperature  rulings,  there  are  spaces  for 
the  date,  the  day  of  disease,  and  for  recording  the  pulse, 
respiration,  amount  of  urine,  and  number  of  the  bowel 
movements,  with  a  marginal  space  for  the  name  of  the 
patient  and  other  necessary  details. 

The  keeping  of  a  simple  clinical  chart  presents  no 
difficulties,  and  pupils  should  be  accustomed  early  to 
keep  them  accurately  and  scrupulously  neat. 

Where  the  pulse  and  respiration,  either  or  both,  are 
recorded  on  the  same  chart,  also  by  dot  and  line,  it  takes 
some  practice  to  make  the  charts  neat  and  clear.  It  is 
usual,  for  the  sake  of  clearness,  to  use  different  colored 
inks  for  the  tracings,  the  scale  being  drawn  on  the  margin 
in  the  same  color  (Plate  IV). 

It  is  often  of  value  to  show  discrepancies  between  the 
normal  ratio  of  temperature,  pulse,  and  respiration  in 
this  manner.  A  clinical  chart  is  issued  with  three  separate 
rulings  on  each  sheet,  to  enable  the  three  records  to  be  kept 
separately,  and  yet  compared  at  a  glance  (Fig.  41,  Plates 
III  and  V).  These  are,  on  the  whole,  more  easily  kept 
neat  and  are  quite  as  satisfactory  as  a  clinical  record. 


PLATE  III 


Medical  chart,  showing  baby's  weight  in  red.     Each  space  equals 
50  grams.     (Courtesy  of  Children's  Hospital,  Boston,  Mass.) 


PLATE  IV 


THE  JOHNS  HOPKINS  HOSPITAL 

JV0.    .  _  ^Admitted 


Four-hourly  chart,  showing  temperature  in  black,  pulse  in  red,  and 
respiration  in  green.     (Courtesy  of  Johns  Hopkins  Hospital.) 


CHARTS 


217 


tet?  *  ">    j_ 


!fi 


# 


13 


Fig.  41a. — Four-hourly  chart  of  temperature,  pulse,  and  respira- 
tion, medical  case,  showing  one  week.  (Courtesy  of  Massachusetts 
General  Hospital,  Boston,  Mass.) 


I 


V. 


Fig.  416. — Daily  chart,  surgical  case.     (Courtesy  of  Massachusetts 
General  Hospital,  Boston,  Mass.) 


218  TEMPERATURE. — PULSE. — RESPIRATION". — CHARTS 

The  ruled  chart  can,  of  course,  be  made  to  serve  as  a  record 
of  any  facts  connected  with  the  disease  which  are  capable 
of  being  measured;  thus,  on  Plates  III  and  VI,  we  have  a 
tracing  of  the  weight;  on  Plate  V,  of  the  urine  and  blood- 
pressure. 

Special  Chart. — Besides  the  clinical  chart,  in  cases  of 
serious  illness  it  is  usual  to  keep  a  special  written  record  in 
which  all  details  of  the  symptoms  and  nursing  can  be  noted. 
Spaces  should  be  ruled  for  the  date,  hour,  the  temperature, 
pulse,  and  respiration,  the  urine  and  bowel  movements, 
and  for  the  record  of  nourishment,  medicines,  and  other 
treatment.  A  margin  is  left  in  which  remarks,  notes,  and 
descriptions  of  symptoms,  and  so  forth  can  be  written 
down.  These  charts  are  a  very  great  help  in  insuring  an 
accurate  report  of  the  case.  At  the  end  of  every  twenty- 
four  hours  a  summary  is  made  giving  the  total  amount  of 
nourishment,  stimulants,  medicines,  etc.,  the  maximum 
and  minimum  temperature,  pulse,  and  respiration,  and  a 
brief  epitome  of  the  patient's  condition  during  the  twenty- 
four  hours  past  (Plate  VII). 

Pupils  should  be  given  plenty  of  practice  in  keeping 
these  charts,  especially  in  writing  them  neatly  and  in 
adding  up  the  quantities  of  drugs  which  are  so  frequently 
given  in  fractional  doses.  Where  the  handwriting  is  very 
bad,  pupils  can  usually  be  taught  to  print. 


PLATE  V 


'S. 


I- 
1: 


3  ° 

C3  rsi 

*H  CJ 

O  -u 


«,  : 


PLATE  VI 


bioo 


THE  JOHNS  HOPKINS  HOSPITAL 

WEIGHT  CHART 


OHhtrlcsl  No..- 


\ 


VY 


X 


/    1'5  13  \3  ll  |5*|l,|s' 


i  ;  x  i  J  ;  >t  I  if  |  (» 


V 


u  (i  [i*  i/y|/u|o|/i  <1 


AA'eight  chart.     (Courtesy  of  Johns  Hopkins  Hospital.) 


PLATE  VII 


Case : 

Dr... 


Polyclinic  Hospital 


Patient's  Name 


ft 


ff 


9* 


ft- 


7* 


Ja 


4. 


ft- 


fir  I**J~/ 


0*4   4-/W 


3/ft    jffrf 


,./.^_c 


Special  chart.     (Model  used  at  Polyclinic  Hospital,  Philadelphia.) 


CHAPTER  VI 
OBSERVATION  AND  EXAMINATION 

Subjective  and  Objective  Symptoms — General  Points  to  be  Ob- 
served— Physical  Examination — Inspection,  Palpation,  Ausculta- 
tion, Rales,  Murmurs,  Percussion— Gynecologic  Positions,  Dorsal 
Recumbent,  Dorsal  or  Lithotomy,  Knee-chest,  Sims',  Trendelen- 
berg — Vaginal  Examination — Packing  the  Vagina — Uterine  Exam- 
ination— Examination  of  Bladder  and  Rectum — Examination  of 
Eye,  Ear,  Nose,  and  Throat — Observation  of  the  Skin :  Abnormal 
Color;  Eruptions;  Other  Alterations — Examination  of  Blood:  Red 
Count;  White  Count;  Varieties  of  White  Cells. 

ONE  of  the  most  important  lessons  that  can  be  taught 
a  nurse  is  to  use  her  power  of  observation.  The  faculty 
of  accurate  observation,  with  a  knowledge  of  the  relative 
value  of  the  facts  observed,  and  the  power  of  accurately 
describing  the  same,  is  probably  of  greater  assistance  in 
making  a  successful  nurse  than  any  other  one  thing. 
In  most  cases  it  is  largely  a  matter  of  training.  This 
must  be  done  in  two  ways,  by  cultivation  of  the  practice 
of  observation  in  the  pupil,  and  by  accurate  teaching  in 
the  matters  to  be  observed  and  their  significance. 

The  clinical  examination  of  patients  is  at  the  present 
day  a  matter  that  may  involve  many  complicated  details 
in  which  the  nurse  may  often  be  required  to  assist.  In 
the  present  chapter  we  shall  go  over  the  principal  common 
methods  of  clinical  examination,  with  some  brief  notice  of 
their  use  and  significance. 

Disease,  or  departure  from  health,  is  perceived,  its 
nature  diagnosed,  and  the  necessary  treatment  determined, 
by  the  observation  and  examination  of  the  person  afflicted. 

Disease  is  manifested  by  symptoms  and  by  physical 
signs. 

SYMPTOMS 

Symptoms  are  divided  into  two  groups— subjective, 
those  complained  of  by  the  patient,  and  objective,  those 
which  may  be  noted  by  the  observer. 

219 


220  OBSERVATION    AND    EXAMINATION 

Subjective  Symptoms. — The  most  important  subjective 
symptoms  are  pain,  discomfort,  sensations  such  as  nausea 
or  giddiness,  defects  of  hearing  and  vision,  and  hallucina- 
tions or  allied  mental  conditions.  To  be  accurate,  the 
report  of  the  subjective  symptoms  should  be  given  in  the 
words  of  the  patient,  and  particularly  so  in  describing 
pain.  The  locality  of  the  pain,  its  character,  whether 
severe  or  slight,  continuous  or  occurring  at  intervals; 
sharp,  piercing,  dull,  aching,  or  throbbing;  whether  in- 
creased by  deep  breathing  or  coughing,  or  mitigated  by 
change  of  position,  and  the  time,  duration,  and  frequency 
of  the  occurrence — are  all  points  important  to  diagnosis 
and  must  be  accurately  noted.  (See  also  p.  701.) 

Where  the  patients  are  young  children,  unconscious, 
delirious,  or  in  conditions  of  extreme  weakness,  an  account 
of  the  subjective  symptoms  is  obviously  impossible  to 
obtain.  A  diagnosis  is  then  obtained  by  an  examination 
of  the  objective  symptoms  and  of  the  physical  signs. 

The  objective  symptoms  include  those  due  to  the 
general  condition  of  the  patient  and  those  which  are  the 
manifestations  of  the  disease  from  which  he  is  suffering. 

The  following  list  suggests  the  more  important  symp- 
toms to  be  noted  and  which  nurses  in  their  work  should 
train  themselves  to  observe. 

The  apparent  bodily  strength,  as  shown  in  the  ability 
to  walk,  stand,  or  sit. 

The  condition  of  the  body,  whether  emaciated  or  plump; 
whether  the  muscles  are  flabby  or  firm. 

The  condition  of  the  skin,  whether  dry,  moist,  or  clammy ; 
undue  redness  of  any  part;  the  presence  and  locality  of 
sores,  scars,  or  eruptions. 

The  color  of  the  skin  and  mucous  membrane,  especially 
of  the  face,  whether  flushed,  pale,  cyanosed,  or  of  an  ab- 
normal color. 

The  presence  and  locality,  and,  as  far  as  possible,  the 
character  of  abnormal  prominences,  swellings,  or  tumors; 
dropsy  in  any  part,  especially  in  the  feet;  enlargement  of 
any  joints;  spots  of  abnormal  tenderness. 

The  surface  warmth  of  the  body,  especially  of  the 
extremities. 


SYMPTOMS  221 

The  temperature  of  the  body,  as  shown  by  the  clinical 
thermometer. 

The  character  of  the  pulse  and  respiration. 

The  mental  condition,  whether  quiet  and  placid,  or 
restless,  excited,  talkative,  fretful,  irrational,  or  delirious, 
unduly  depressed  and  melancholy,  or  unconscious. 

The  facial  expression,  which  is  frequently  of  impor- 
tance, evincing  pain,  anxiety,  apathy,  ecstasy,  or  other 
emotions. 

The  odor  of  the  breath:  it  may  be  heavy  from  gastric 
disturbances,  offensive  from  the  presence  of  decayed 
teeth,  or  fetid  from  disease,  such  as  scurvy;  alcohol  and 
a  few  drugs  impart  a  characteristic  odor  to  the  breath 
which  may  be  of  diagnostic  importance. 

The  appearance  of  the  abdomen:  it  may  be  distended 
with  gas,  enlarged  by  the  presence  of  fluid  or  tumor,  or 
hollowed  out,  as  in  conditions  of  great  emaciation. 

The  appearance  of  the  eyes,  whether  sunken  or  unduly 
prominent;  any  inflammation  or  discharge  from  the  lids; 
unusual  contraction,  dilatation,  or  inequality  of  the  pupils. 

The  condition  of  the  nose  and  the  character  of  any 
discharge. 

The  condition  of  the  mouth,  which  is  an  important 
indication  of  many  conditions;  this  will  include  an  exam- 
ination of  the  teeth,  gums,  and  tongue.  It  should  be 
noted  whether  the  teeth  are  permanent  or  false,  firm  or 
loose,  sound  or  decayed,  clean  or  covered  with  sordes; 
whether  the  gums  are  normal,  or  swollen  with  a  tendency 
to  bleed  easily.  The  tongue  may  be  clean  or  coated, 
furred  in  the  center  or  all  over,  dry,  brown,  or  fissured,  as 
in  cases  of  profound  toxemia,  covered  with  patches,  as  in 
thrush,  or  ulcerated,  as  in  stomatitis,  or  it  may  have  some- 
thing of  the  color  and  appearance  of  a  ripe  strawberry, 
a  condition  -seen  in  scarlet  fever. 

The  throat  should  also  be  examined,  especially  in  young 
children,  who  do  not  complain  of  their  troubles.  Any 
redness  or  swelling  and  the  character  of  any  patches  or 
the  presence  of  discharge  should  be  noted. 

The  gait  of  the  patient,  lameness,  inability  to  place  a 
foot  on  the  ground,  inversion  or  aversion  of  the  foot, 


222  OBSERVATION   AND   EXAMINATION 

dragging   of  the   limbs,  and   inability   to  walk  without 
looking  at  the  feet,  are  all  points  of  diagnostic  value. 

Certain  symptoms  are  manifestations  of  certain  condi- 
tions and  should  be  accurately  observed. 

1.  Paralysis  in  any  part  of  the  body,  such  as  the  limbs, 
part  of  the  face,  throat,  or  vocal  cords,  evinced  by  an 
insensibility  to  touch  or  an  inability  to  perform  their 
functions  (p.  709). 

2.  Tremor  or  subsultus:  a  condition  of  general  trembling, 
noticed  at  the  onset  of  delirium  tremens,  and  in  some  con- 
ditions of  great  prostration;  irrational  movements,  such  as 
picking  at  the  bed-clothes  (carphology) ,  a  symptom  noticed 
in    profound    prostration,    uncontrolled    twitchings    or 
movements,  such  as  those  seen  in  chorea. 

3.  Persistent    hiccough   (singultus),    frequently   due   to 
gastric  irritation,   is  also  associated  with  certain  brain 
diseases,  and  is  a  serious  symptom  in  conditions  of  severe 
toxemia  or  great  exhaustion  (p.  715). 

4.  Involuntary  evacuations  which  may  be  due  to  paralysis 
or  imperfection  of  the  sphincter  ani,  persistent  diarrhea, 
or  to  the  mental  condition  of  the  patient. 

5.  Incontinence  of  urine,  which  may  be  caused  by  an 
overdistended  bladder,  paralysis  of  the  urethra  or  sphinc- 
ters, or  due  to  the  mental  condition  of  the  patient. 

6.  Vomiting. — The  time,  frequency,  and  character  of  the 
act  of  vomiting.     The  vomitus  itself  should  be  inspected 
minutely,  and  the  first  vomitus  of  any  patient  should  in- 
variably be  saved  for  examination  (pp.  256  and  712). 

7.  Convulsions.— The    time,    frequency,    and    duration 
of  the  convulsions,  together  with  the  character  of  the 
movements,  and  any  physical  manifestations  which  ac- 
company the  attack  (p.  677). 

8.  Unusual  cries,  such  as  the  sharp,  piercing  cry  heard 
in  meningitis,  the  characteristic  night  cry  common  in  hip- 
joint  disease,  or  the  wailing  cry  of  an  ill-nourished  infant. 

The  above  are  all  conditions  that  may  be  noticed  by  the 
nurse  in  her  attendance  on  the  patient  and  on  her  obser- 
vation of  which  the  doctor  is,  to  some  extent,  dependent 
in  making  his  diagnosis. 


PHYSICAL  SIGNS  223 

PHYSICAL  SIGNS 

Besides  the  subjective  and  objective  symptoms  just 
enumerated,  the  diagnosis  of  a  disease  depends  also  on  an 
examination  of  what  are  known  as  physical  signs.  Phy- 
sical signs  are  those  manifestations  of  a  departure  from 
the  normal  condition  of  an  organ  detected  in  an  examina- 
tion of  the  organ  by  the  eye,  ear,  and  touch.  The  methods 
employed  are  known  as  inspection,  palpation,  auscultation, 
and  percussion.  While  these  examinations  are  carried 
out  by  the  physician,  an  important  part  of  a  nurse's  duties 
consists  in  preparing  patients  for  such  examinations,  and 
in  many  instances  she  may  be  required  to  help. 

Inspection,  or  examination  by  sight,  is  an  observation 
of  the  appearance  of  that  area  of  the  body  immediately 
covering  the  organ  under  examination;  its  object  is  to 
detect  any  departure  from  the  normal  size  and  aspect,  and 
the  presence  of  abnormal  swellings,  prominences,  tumors, 
discolorations,  or  malformations.  When  the  organ  has 
a  function  with  manifestations  of  movement,  the  observa- 
tion of  such  movements  is  included  in  the  inspection;  for 
example,  inspection  of  the  heart  will  include  observation  of 
the  position  and  force  of  the  apex-beat  against  the  chest- 
wall,  and  will  show  whether  either  position  or  force  is 
changed  by  change  in  the  position  of  the  patient;  inspec- 
tion of  the  lungs  will  include  observation  of  the  move- 
ments of  the  chest  and  abdominal  walls  during  respiration. 

Palpation  is  examination  by  touch,  and  is  performed 
by  laying  the  open  palm  and  fingers  flat  on  the  body  over 
the  organ  to  be  examined.  To  some  extent  it  verifies  the 
examination  by  inspection.  It  further  detects  points  of 
tenderness  and  soreness,  and  determines  the  character 
and  condition  of  abnormal  prominences,  swellings,  and 
tumors.  For  example,  palpation  will  determine  whether 
an  enlarged  abdomen  is  due  to  distention  by  gas,  to  the 
presence  of  a  solid  tumor,  or  to  a  collection  of  fluid  in  the 
abdominal  cavity. 

A  special  group  of  symptoms  is  also  examined  by  pal- 
pation. These  cause  a  sensation  of  tremor  or  thrill 
under  the  examining  hand,  some  of  which  are  normal 
and  others  abnormal  and  diagnostic  of  disease.  Such  a 


224  OBSERVATION   AND    EXAMINATION 

tremor  is  spoken  of  as  a  fremitus,  and  is  frequently  likened 
to  the  thrill  felt  when  stroking  a  purring  cat. 

A  normal  fremitus  may  be  observed  by  keeping  the 
palm  on  the  chest  during  the  act  of  speaking,  crying,  or 
coughing.  This  normal  fremitus  is  modified,  to  a  great 
extent,  in  disease,  and  others  not  normally  present  exist. 

A  thrill  may  be  felt  over  the  region  of  the  heart  in  such 
disorders  of  the  circulation  as  are  caused  by  valvular 
heart  disease  or  aneurysm  of  the  aorta. 

A  peculiar  vibration,  known  as  a  friction  fremitus,  is 
observed  where  two  serous  surfaces  roughened  by  inflam- 
mation rub  together,  as  in  the  case  of  pericarditis  or  of 
pleurisy. 

The  character  of  the  fremitus  and  the  point  at  which  it 
is  most  distinctly  felt  are  of  diagnostic  importance. 

Auscultation,  or  examination  by  the  ear,  may  be  carried 
out  by  the  ear  alone  held  against  the  surface  directly  over 
the  organ,  or  by  the  stethoscope.  All  those  signs  which 
manifest  themselves  by  sound  are  examined  by  ausculta- 
tion; such  are  the  movements  of  air  in  the  air-passages,  or 
blood  in  the  blood-vessels,  and  the  grating  sound  caused 
by  the  friction  of  inflamed  surfaces  rubbing  together. 
Abnormal  sounds  are  heard  in  diseases  accompanied  by 
alterations  in  the  air-passages  or  in  the  blood-stream  in 
the  blood-vessels.  These  are  spoken  of  as  new  or  adven- 
titious sounds.  If  connected  with  the  air-passages,  they 
are  known  as  rales;  if  connected  with  the  blood-vessels, 
as  murmurs.  Friction-sounds  not  being  perceptible  in 
health  belong  also  to  the  class  of  adventitious  sounds. 
These  rales,  murmurs,  and  friction-sounds  are  very  fre- 
quently referred  to  in  describing  diseases.  Their  signifi- 
cance, therefore,  should  be  understood. 

Rales. — When  the  air  on  inspiration  or  expiration 
passes  through  liquid  secretions,  as  in  the  case  of  catarrhal 
or  inflamed  conditions  of  the  lungs  or  air-passages,  sounds 
of  bubbling  and  crackling  are  heard  through  the  chest- 
walls;  these  are  known  as  moist  rales,  their  variety  being 
an  important  aid  to  diagnosis.  A  sound  caused  by  a 
similar  condition  is  heard  in  what  is  commonly  known  as 
the  death-rattle,  where  the  trachea  becomes  blocked  with 


PHYSICAL   SIGNS  225 

mucus  through  which  the  air  is  breathed.  The  sounds  of 
the  rales  are  qualified  by  the  thickness  of  the  secretions 
and  the  size  of  the  tubes  over  which  they  are  heard. 
According  to  the  sound,  they  are  spoken  of  as  fine,  coarse, 
crackling,  bubbling,  or  gurgling  rales.  Where  the  air  passes 
through  a  tube  of  which  the  diameter  is  diminished  by 
inflammatory  processes,  the  abnormal  sounds  thus  caused 
are  spoken  of  as  dry  rales,  and  are  sibilant  or  sonorous, 
according  to  the  pitch.  The  rales  are  also  grouped  under 
the  name  of  the  areas  where  they  occur.  Thus  we  have 
tracheal  rales,  bronchial  rales,  and  the  vesical  rales  heard 
over  the  air- vesicles;  the  latter  are  also  frequently  called 
crepitant  (crackling)  rales,  from  the  characteristic  sound 
they  produce. 

Murmurs  are  due  to  changes  in  the  directions  of  the 
blood-currents,  usually  caused  either  by  obstruction  of  a 
valve,  which  impedes  the  flow  of  blood,  or  insufficiency 
of  a  valve,  which  allows  the  blood  to  regurgitate  into  one 
or  other  chamber  of  the  heart;  they  may  also  be  due 
to  the  presence  of  an  aneurysm  in  one  of  the  blood- 
vessels. They  are  audible  over  the  area  of  the  heart  or 
over  the  course  of  certain  blood-vessels,  and  are  likened 
to  the  blowing  sound  made  by  a  pair  of  bellows.  Murmurs 
may  also  be  due  to  conditions  where  the  blood  itself  is 
seriously  altered,  as  in  anemia.  These  are  spoken  of  as 
hemic  or  inorganic  murmurs. 

The  peculiar  sound  of  the  murmur,  the  area  over  which 
it  is  heard,  and  the  time  of  its  occurrence,  whether  during 
or  after  dilatation  or  contraction,  are  all  of  diagnostic 
importance. 

Friction-sounds  heard  through  the  chest-wall  are  caused 
by  the  rubbing  together  of  the  surfaces  either  of  the 
pleura  or  of  the  pericardium,  when  they  have  been  rough- 
ened by  inflammation. 

Percussion  is  a  second  method  of  examination  by  the 
ear.  By  placing  a  finger  of  the  left  hand  directly  over  the 
point  of  examination  and  striking  it  lightly  with  the  tips 
of  the  first  or  second  fingers  of  the  right  hand,  notes  of 
varying  pitch  are  produced,  according  to  the  density  .of 
the  underlying  structure  (Fig.  42) .  By  these  means  an  area 

15 


226 


OBSERVATION   AND    EXAMINATION 


occupied  by  an  organ  is  mapped  out  and  changes  in  its 
structure  affecting  its  density  are  detected;  the  resonance 
of  the  lung  is  studied,  and  its  elasticity  or  resistance  deter- 
mined. 

The  above  brief  description  of  the  methods  of  physical 
examination  and  the  significance  of  the  physical  signs  so 

demonstrated  are  for  the 
purpose  of  making  more 
readily  understood  the 
characteristic  symptoms 
and  manifestation  of  cer- 
tain diseases,  and  the  aim 
and  direction  of  the  differ- 
ent methods  of  treatment. 
It  is  not,  obviously,  in  any 
sense  to  be  understood  as 
a  guide  to  an  examination 

fof  a  patient,  such  an  ex- 
amination being  purely  for 
the  purpose  of  diagnosis, 
and  not  included  in  the 
duties  of  a  nurse.  Some 
of  the  terms,  however,  are 
|  \  so  constantly  referred  to, 

both  in  practice  and  in  all 
text-books  which  it  may  be 
desirable  to  consult,  that  an  understanding  of  their  mean- 
ing and  significance  is  not  only  convenient,  but  necessary. 
When  the  patient  is  not  confined  to  bed,  it  is  usually 
preferred  to  examine  the  chest  with  the  patient  either 
standing  or  sitting  upright ;  in  most  hospital  cases  this  is, 
however,  out  of  the  question.  In  examining  the  chest 
in  front  the  arms  are  usually  held  hanging  straight  from 
the  shoulder;  in  examining  the  side,  the  hands  are  crossed 
above  the  head;  when  the  back  is  examined,  the  arms  are 
crossed  in  front  and  the  head  bent  forward.  In  a  young 
child  an  excellent  method  of  examining  the  back  of  the 
chest  is  as  follows: 

•  The  child  is  taken  on  the  left  arm  of  the  nurse,  the 
buttocks  supported  by  the  arm,  the  front  of  the  chest 


Fig.  42. — Percussion  (DaCosta). 


PHYSICAL   SIGNS 


227 


flat  against  her  breast.  The  head  hangs  a  little  downward 
over  her  shoulder,  and  may  be  held  in  place  by  her  left 
hand.  Usually  the  child  feels  comfortable  and  will 
remain  still  better  in  this  position  than  in  any  other. 
To  examine  the  front  of  the  chest  in  a  young  child  the 
child  is  held  on  the  back  across  the  knees,  the  head  falling 
a  little  backward,  and  the  arms  held  together  above  the 


Fig.  43. — Listening  to  the  back  of  a  baby's  chest. 

head.  If  the  arms  are  to  be  kept  to  the  side,  they  may  be 
pinioned  in  the  following  way: 

Fold  a  hand-towel  in  half  lengthways,  and  lay  it  cross- 
ways  under  the  baby's  back.  Bring  the  ends  up  on  either 
side  between  the  arms  and  the  chest,  and  tuck  them  in 
over  the  extended  arms  and  under  the  back. 

In  all  physical  examinations  the  points  essential  for  a 
nurse  to  consider  are  the  following:  The  room  must  be 


228 


OBSERVATION   AND   EXAMINATION 


warm;  the  light  good;  the  patient  comfortable,  never 
unnecessarily  exposed,  and  kept  comfortably  supported 
without  movement  during  the  examination.  During  aus- 
cultation and  percussion  the  room  must  be  absolutely 
quiet.  After  the  examination  the  patient  should  be  warmly 
covered  and  induced  to  rest.  If  exhausted,  some  nourish- 
ment is  given;  in  some  cases  a  stimulant  is  ordered.  For 


Fig.  44. — Auscultating  the  chest,  showing  the  arms  fixed  by  the  side. 

inspection  it  is  obviously  necessary  to  remove  the  garment- 
For  the  rest  of  the  examination  the  covering  is  usually 
resumed  or  replaced  by  a  towel  or  any  covering  of  smooth 
material.  When  the  chest  is  hairy,  the  nurse  may  be 
directed  to  wet  the  hair  with  warm  water,  as  when  rubbing 
against  the  stethoscope  the  hairs  produce  very  definite 
sounds. 


EXAMINATION   OF  SPECIAL   ORGANS 


EXAMINATION  OF  SPECIAL  ORGANS 


229 


In  special  cases  it  is  necessary  to  examine,  either  by 
inspection  or  by  digital  examination,  the  cavities  of  the 
body,  the  vagina,  the  uterus,  the  bladder,  or  the  rectum. 

When  an  examination  of  a  special  organ  is  to  be  made, 
the  patient  may  be  asked  to  assume  certain  positions, 
according  to  the  nature  of  the  examination  required. 
The  positions  are  more  especially  applicable  in  gyneco- 
logic work.  The  usual  positions  are  known  by  the  follow- 
ing terms: 

Horizontal  or  Dorsal  Recumbent  Position. — The  patient 
lies  on  the  back,  one  pillow  only  under  the  head.  The 
legs  are  separated  and  the  knees  slightly  flexed.  The 
horizontal  position  is  used  for  the  ordinary  digital  examin- 


Fig.  45. — Dorsal  recumbent  posture  (American  Illustrated  Medical 
Dictionary) . 

ation.     The   examiner   usually   stands   on   the   patient's 
right,  in  order  to  use  the  right  hand  for  examination. 

Dorsal  or  Lithotomy  Position. — -The  patient  lies  on  the 
back,  either  across  the  bed,  the  buttocks  resting  on  the 
edge  of  the  mattress,  or,  if  on  the  examining  table,  with 
the  buttocks  brought  to  the  edge  of  the  table.  A  flat 
pillow  is  usually  placed  below  the  buttocks,  in  order  to 
raise  the  pelvis.  The  legs  are  well  separated,  and  the 
knees  acutely  flexed.  To  maintain  this  position  it  is 
necessary  to  support  the  feet  and  keep  the  knees  immov- 
able. An  examination  table  is  usually  provided  with 
"  crutch  and  stirrup  "  for  this  purpose.  The  crutch  is 
a  rod  adjusted  to  a  socket  at  the  lower  end  of  the  table 
(one  at  either  side),  to  which  a  stirrup  or  foot  support  is 
attached.  The  stirrups  are  made  of  webbing,  and  are 


230 


OBSERVATION   AND   EXAMINATION 


hung  from  the  crutch  at  the  height  convenient  to  support 
the  foot.  When  the  patient  is  in  bed,  she  may  be  directed 
to  place  the  heels  on  the  edge  of  the  mattress  or  on  a  small 
table  or  chair  placed  conveniently  near  on  either  side. 
The  nurse,  then,  standing  by  the  bed  on  the  patient's 


Fig.  46. — Lithotomy  position  (Ashton). 

right  side,  holds  the  knees  apart;  the  examiner  usually 
sits  on  a  chair  exactly  opposite  the  patient.  Where  it  is 
necessary  to  control  the  movements  of  the  patient,  two 
nurses  are  needed,  one  on  either  side;  the  knee  is  encircled 


Fig.  47. — Lithotomy  position,  with  leg-holder  applied  (American 
Illustrated  Medical  Dictionary). 

in  one  arm,  the  foot  being  held  in  the  other  hand.  Other 
means  sometimes  used  are  to  tie  each  ankle  to  the  wrist 
on  the  same  side  with  a  wide  piece  of  bandage;  or  a  long 
wide  bandage  may  be  passed  behind  the  shoulders  and 
round  the  thigh,  just  above  the  knee  (Fig.  47).  This  posi- 


EXAMINATION   OF   SPECIAL  ORGANS  231 

tion  is  used  for  examination  and  operations  on  the  peri- 
neum, vagina,  cervix  (the  neck  of  the  uterus  which  hangs 
free  in  the  upper  part  of  the  vagina),  and  uterine  cavity, 
and  for  digital  examination  of  such  parts  of  the  pelvis  as 
can  be  felt  through  the  vaginal  wall ;  for  examination  of  the 
bladder  and  rectum  and  for  the  majority  of  operations  on 
the  bladder  and  rectum. 

Knee-chest,  or  Genupectoral,  Position. — In  this  position 
the  patient  kneels  on  the  bed  or  examining  table  and  bends 
forward  until  the  chest  rests  on  the  bed,  the  abdomen  re- 
maining unsupported.  The  head  is  turned  to  one  side,  rest- 
ing on  the  cheek,  and  the  arms  are  extended.  A  small  pil- 
low is  allowed  under  the  chest.  The  knee-chest  position  is 
very  common  in  gynecologic  work,  not  only  for  purposes 
of  examination,  but  in  order  to  overcome  displacements 


Fig.  48. — Knee-chest,  or  genupectoral,  posture  (American  Illustrated 
Medical  Dictionary). 

and  for  the  introduction  of  pessaries.  Patients  usually  re- 
quire to  be  taught  the  position,  their  inclination  being  to 
rest  the  abdomen  against  the  flexed  thighs.  As  the  object 
most  frequently  is  to  allow  the  pelvic  organs  to  fall  for- 
ward, the  object  is  defeated  if  the  abdomen  is  supported. 
The  knee-chest  position  is  also  a  common  one  in  making 
a  rectal  examination  and  in  giving  colonic  flushing.  The 
simple  purgative  enema  is  often  more  effectual  if  given  in 
this  position. 

Sims'  Position. — This  is  so  called  after  a  famous  gyne- 
cologist who  first  employed  it.  It  is  also  known  as  the 
left  lateral  position.  The  patient  lies  on  the  left  side,  the 
cheek  resting  naturally  on  the  pillow  (one  small  pillow 
only  is  allowed),  the  buttocks  brought  to  the  edge  of  the 


232 


OBSERVATION   AND   EXAMINATION 


bed,  so  that  the  body  lies  diagonally  across  the  bed.  She 
is  then  directed  to  place  her  left  arm  behind  her  back; 
this  will  turn  the  body  with  the  right  shoulder  forward, 
so  that  the  patient  is  lying  partly  on  her  chest,  and  the 
right  hip  is  tilted  more  forward  than  the  left.  Both  knees 
are  drawn  up  at  right  angles  to  the  body,  and  the  right 


Fig.  49. — Sims'  position,  anterior  view  (American  Illustrated  Medical 
Dictionary) . 


knee  crossed  over  the  left,  so  that  it  rests  on  the  bed. 
The  position  is  peculiarly  favorable  for  obtaining  a  clear 
view  of  the  cervix  and  dome  of  the  vagina.  With  the 
body  tilted  in  this  position  the  abdominal  viscera  fall 
away  from  the  pelvic  floor,  while  the  flexion  and  crossing 


Fig.  50. — Sims'  position,  posterior  view  (American  Illustrated  Medir 
cal  Dictionary) . 

forward  of  the  right  thigh  exposes  the  orifice  of  the  vagina. 
The  Sims'  speculum  is  passed,  and  the  perineum  held 
back;  this  exposes  the  vaginal  cavity  freely,  and  admits 
a  certain  amount  of  air,  which  distends  the  vagina  and 
thus  further  facilitates  the  examination  of  the  cervix  and 
adjacent  tissues. 


EXAMINATION   OF  SPECIAL   ORGANS 


233 


The  Sims  position  is  especially  used  for  inspection 
and  for  treatment  of  minor  operations  on  the  cervix  and 
anterior  wall  of  the  vagina.  With  many  surgeons  it  is 
a  favorite  position  for  the  repair  of  vesicovaginal  fistula 
(an  artificial  opening  between  the  bladder  and  the  vagina). 
In  order  further  to  keep  the  mouth  of  the  vagina  free,  the 
nurse  may  be  directed  to  elevate  and  support  the  right 
thigh.  She  may  hold  it  in  the  required  position,  or, 
especially  if  the  examination  is  a  long  one,  place  a  double 
pillow  or  rolled  blanket  between  the  knees. 

The  above  is  the  true  Sims  position;  for  a  simple  digital 
examination  of  the  cervix,  etc.,  where  a  picture  of  the 
parts  is  not  necessary,  many  surgeons  use  a  modification 
of  the  above,  in  which  the  left  leg  is  fully  extended;  the 
position  is  otherwise  the  same.  In  this  circumstance  it 
is  not  necessary  to  expose  the  patient.  For  some  examina- 
tions one  or  two  pillows  are  placed  below  the  left  hip, 
thus  raising  the  pelvis  and  tilting  the  right  hip  further 
forward:  this  is  known  as  the  elevated  Sims  position. 

Trendelenburg  position,  also  named  after  the  gyne- 
cologist who  employed  it,  is  not,  properly  speaking,  an 


Fig.  51. — Trendelenburg  position  (Ashton). 


examining  position.  It  is  at  the  present  time  the  usual 
position  in  which  abdominal  operations  on  the  pelvic 
organs  are  performed,  and  operating  tables  are  usually 
made  so  that  they  can  be  easily  adjusted  to  the  required 
position.  When  this  is  not  the  case,  the  patient  is  placed 
in  the  dorsal  position,  with  the  knees  flexed  over  the  lower 


234 


OBSERVATION   AND    EXAMINATION 


edge  of  the  table  and  the  feet  comfortably  secured  to  the 
legs  of  the  table.  The  head  is  turned  to  one  side,  resting 
on  the  cheek;  the  lower  end  of  the  table  is  then  raised  to 
the  required  angle,  bringing  the  hips  high  above  the 
shoulders.  In  this  position  the  abdominal  viscera  fall 
toward  the  floor  of  the  chest  and  away  from  the  pelvis, 
leaving  the  pelvic  organs  more  readily  manipulated  when 
the  abdomen  is  opened. 

If  it  is  necessary  to  put  the  patient  in  the  Trendelen- 
burg  position  in  the  ordinary  bed,  a  long-backed  chair  may 
be  converted  into  an  inclined  plane  by  being  turned  up- 
side down  and  laid  with  the  front  edge  of  the  seat  and  the 
top  of  the  back  resting  on  the  mattress,  the  chair-legs 
directed  toward  the  bottom  of  the  bed.  The  plane  so 


Fig.  52. — Improvised  Trendelenburg  position  (Dickinson). 

formed  is  comfortably  padded  with  a  pillow  or  a  blanket. 
The  legs  are  flexed  over  the  bars  of  the  chair,  and  comfort- 
ably secured  to  its  legs,  the  patient  lying  along  the  back 
of  the  chair.  The  lower  end  of  the  bedstead  may  then 
be  raised  on  blocks.  In  using  the  Trendelenburg  posi- 
tion for  any  length  of  time  it  is  usually  considered  desirable 
to  change  the  angle  from  time  to  time.  In  the  ordinary 
operating  or  examination  table  the  adjustment  is  made  by 
means  of  a  cog-wheel,  with  the  manipulation  of  which 
nurses  should  be  made  familiar. 

More  rarely  the  patient  is  examined  standing.  A 
stool  is  provided  on  which  one  foot  is  rested,  the  legs  being 
separated  as  far  as  is  comfortable.  The  patient  supports 
herself  by  grasping  the  back  of  a  chair  (Fig.  53). 

In  all  the  above  conditions  no  part  of  the  patient  is 


EXAMINATION   OF   SPECIAL   ORGANS 


235 


exposed  except  that  to  be  immediately  examined.  The 
night-dress  should  be  rolled  out  of  the  way  above  the 
waist,  and  the  heavier  bed-coverings  removed.  In  the 
horizontal  position  the  sheet  may  be  left  over  the  patient, 
the  sides  and  bottom  untucked,  and  no  exposure  at  all 
is  necessary.  In  hospitals,  for  the  Sims,  knee-chest, 
and  dorsal  positions  special  ex- 
amination sheets  are  usually  pro- 
vided, large  enough  to  cover  the 
patient,  and  made  with  an  open- 
ing which  can  be  adjusted  over 
the  area  to  be  examined.  Where 
these  are  not  provided,  a  couple 
of  sheets  or  draw-sheets,  pinned 
together  at  the  margin,  leaving 
an  opening  at  a  suitable  point, 
are  practicable.  In  any  circum- 
stance two  sheets,  one  above 
and  one  below,  can,  with  a  little 
ingenuity,  be  made  to  serve. 
The  sheets  should  not  be  tucked 
under  the  mattress,  as  altera- 
tion in  the  position  is  thereby 
impeded. 

For  the  dorsal  position  stockings  or  leggings  should 
cover  the  legs,  and,  if  an  examination  sheet  is  not  used, 
one  sheet  should  cover  the  body  to  the  pubes,  while 
the  second  is  placed  below  the  buttocks;  the  sides  are 
brought  up  on  the  outside  and  tucked  round  the  thighs. 
If  a  douche  is  given  in  this  position,  a  Kelly  pad  is  placed 
below  the  buttocks,  the  rubber  apron  directed  into  a 
bucket  on  the  floor. 

In  the  standing  position  the  skirts  are  removed  and 
replaced  by  a  sheet  pinned  round  the  waist  in  such  a  way 
that  the  opening  is  toward  the  examiner. 

For  a  vaginal  examination  both  rectum  and  bladder 
should  be  empty.  A  table  is  placed  conveniently,  provided 
with  the  following  articles,  ready  sterilized,  and  laid  on 
a  sterile  towel;  a  second  sterile  towel  covers  them  until 
ready  to  be  used: 


Fig.  53. — Standing  posi- 
tion (Ashton). 


236  OBSERVATION   AND    EXAMINATION 

One  pair  of  rubber  gloves. 

Sterile  lubricant. 

Sims'  speculum. 

Uterine  sound. 

Uterine  forceps  or  sponge-holder. 

Applicators. 

Tube  of  gauze  packing. 

One  package  of  small  gauze  sponges. 

One  package  containing  a  small  quantity  of  absorbent 
cotton. 

Basin  of  hot  sterile  water  (100°  F.). 

Small  bottles  containing  any  applications  desired,  such 
as  iodin,  etc.,  may  be  placed  ready  on  a  tray  containing 
also  a  sterile  glass  measure  into  which  the  small  amount 
necessary  can  be  poured. 

A  basin  of  antiseptic  solution  for  the  hands  is  also 
provided  in  case  the  technic  is  accidentally  broken.  The 
gloves  are  for  the  hands  of  the  examiner. 

The  lubricant  provided  may  be  sterile  vaselin  or  an 
emulsion  of  Castile  soap.  Many  dispense  with  the  use  of 
lubricants  entirely. 

The  Sims'  speculum  is  a  half  cylinder  made  of  plated 
metal  mounted  on  a  handle.  It  is  used  to  enlarge  the 
vaginal  orifice  by  retracting  the  perineum,  while  its 
brightly  plated  surface  acts  as  a  reflector,  increasing  the 
light  for  purposes  of  inspection.  It  is  usually  advisable 
to  have  an  artificial  light  and  a  head-mirror  (see  below) 
in  readiness  in  case  the  available  light  is  not  sufficient. 
It  is  frequently  the  nurse's  duty  to  hold  the  speculum  in 
position.  She  should  be  careful  to  hold  it  immovable,  as, 
if  she  changes  the  position,  a  different  part  of  the  vaginal 
wall  will  be  held  back  and  she  may  interfere  materially 
with  the  object  of  the  examination.  Other  specula 
sometimes  used  are  in  the  form  of  complete  cylinders  of 
varying  sizes,  the  inner  surf  ace  of  which  is  brightly  polished. 
They  may  be  made  of  metal,  or  more  generally  of  glass, 
the  outer  surface  of  which  is  darkened  and  the  inner 
surface  silvered.  If  a  nurse  is  directed  to  lubricate  a 
speculum,  she  must  be  careful  to  lubricate  only  the  outer 
surface,  otherwise  the  reflecting  inner  surface  is  dulled. 


EXAMINATION   OF   SPECIAL  ORGANS  237 

The  applicators  are  "mounted"  with  small  strands  of 
absorbent  cotton.  To  do  this  a  very  thin  strand, 
about  two  inches  long  and  one-half  inch  wide,  is  taken 
between  the  finger  and  thumb  of  the  left  hand.  The 
applicator  is  a  small,  roughened  metal  rod,  mounted 
on  a  long  handle.  It  is  taken  in  the  right  hand,  the 
tip  placed  between  the  finger  and  thumb  of  the  left 
hand,  and,  by  a  quick  rotatory  movement  of  the  right 
hand,  the  cotton  is  securely  wound  round  the  tip  of  the 
applicator.  A  little  practice  is  necessary  to  perform  this 
deftly.  The  applicator  is  then  dipped  in  the  required 
solution.  A  thick  piece  of  cotton  must  not  be  used,  other- 
wise it  is  apt  to  become  detached  and  left  in  the  cavity. 
Applications  to  the  cervix,  such  as  iodin,  etc.,  are  thus 
used  directly  on  one  spot  without  danger  of  dropping  the 
application  on  other  parts. 

In  order  to  pack  the  vagina  the  uterine  forceps  or  sponge- 
holders  are  used.  Sponges  may  be  necessary  to  dry  up 
secretions,  small  points  of  bleeding,  etc.;  the  hot  water  is 
to  warm  the  instruments  before  use. 

The  uterine  sound  is  a  long  probe  of  polished  metal 
marked  off  into  inches  or  centimeters;  2^  inches  from  the 
tip  there  is  a  slight  enlargement.  The  sound  is  used  for 
measuring  the  cavity  of  the  uterus,  the  normal  depth  of 
which  is  2^  inches.  The  enlargement  at  this  point  shows 
quickly  whether  or  not  the  cavity  is  normal. 

The  nurse's  part  in  such  an  examination  lies  entirely 
with  the  patient.  She  may  be  asked  to  pour  out  some 
application,  but  must  be  careful  to  touch  nothing  sterile 
on  the  table. 

In  some  cases  the  nurse  may  be  required  to  prepare 
the  cervix  dilators.  These  dilators  are  small,  solid  instru- 
ments, usually  either  of  silver  or  hard  rubber,  shaped  like 
a  pencil,  slightly  curved,  about  3^  inches  long,  and  of 
varying  diameters.  Usually  a  set  contains  12;  they  should 
be  arranged  on  the  table  in  order  of  gradation,  convenient 
to  the  examiner's  hand.  Silver  dilators  are  sterilized 
by  boiling,  and  should  be  warmed  before  introduction; 
hard-rubber  dilators  would  lose  their  shape  if  boiled,  and 
are  usually  placed  in  alcohol  (70  per  cent.)  at  least  half 


238  OBSERVATION   AND   EXAMINATION 

an  hour  before  use.  A  sterile  lubricant  should  be  provided, 
and  the  Sims'  speculum,  with  which  the  vaginal  orifice  is 
held  open  during  the  dilatation. 

The  patient,  for  this  process,  lies  either  in  the  lithotomy 
position  or  the  Sims  position;  if  inspection  of  the  part  is 
also  desired,  the  latter  is  usually  preferred. 

Bladder  Examination. — For  examination  or  treatment 
of  the  bladder  the  patient  lies  in  the  lithotomy  position. 
Dilators  for  the  examination  of  the  bladder  are  straight, 
hollow,  cylindric  instruments,  of  varying  diameter, 
usually  of  silver,  which  can  be  sterilized  by  boiling.  The 
dilators,  arranged  according  to  size,  are  introduced  in  turn 
into  the  urethra;  a  sterile  lubricant  is  usually  required. 
The  examination  is  made  in  a  darkened  room,  with  arti- 
ficial light  and  head-mirror  (see  below);  the  polished  inner 
surface  of  the  dilators  acts  as  a  speculum,  and  helps  to 
illuminate  the  cavity.  A  special  dilator  sometimes  used 
is  provided  with  a  small  electric  bulb  at  the  tip.  When  it 
is  in  place,  the  electric  current  is  turned  on  and  the  in- 
terior of  the  bladder  illuminated.  This  dilator  is  especially 
useful  where  it  is  desired  to  catheterize  the  ureters,  the 
vessels  which  conduct  the  urine  from  the  kidneys  to  the 
bladder. 

To  catheterize  the  ureters  long,  fine,  filiform  catheters 
are  used,  which  must  be  carefully  sterilized,  usually  in  the 
autoclave.  The  patient  lies  in  the  lithotomy  position; 
the  urethra  is  well  dilated,  and  the  dilator  kept  in  position 
while  the  catheters  are  passed;  once  the  catheters  are  in 
position,  the  dilator  is  generally  removed.  As  it  is  usually 
of  the  first  importance  to  distinguish  between  the  secre- 
tions of  the  two  kidneys,  one  of  the  catheters  should 
have  some  distinguishing  mark,  such  as  a  piece  of  silk 
threaded  through  the  open  end.  A  note  in  writing  should 
be  made  as  to  whether  the  marked  catheter  is  passed  into 
the  left  or  right  ureter.  A  couple  of  sterile  test-tubes, 
also  marked  right  and  left,  must  be  provided  to  catch  the 
secretion.  The  open  ends  of  the  catheters  are  introduced 
into  the  respective  tubes,  which  are  corked  with  sterile 
cotton,  packed  lightly  round  the  catheter. 

For  a  rectal  examination  hollow  dilators  similar  to 


EXAMINATION   OF   ORGANS   OF   SPECIAL   SENSE      239 

those  for  a  bladder  examination,  but  of  a  considerably 
larger  size,  are  used.  The  patient,  as  a  rule,  is  in  the 
knee-chest  position.  Frequently  applications  are  made 
through  the  dilators  On  fissures  or  ulcers  that  can  be 
reached  through  the  rectum.  An  artificial  light  and  head- 
mirror  are  practically  always  necessary. 

These  examinations  are  always  peculiarly  trying  to  the 
patient,  and  are  necessarily  made  more  so  if  the  nurse 
fails  to  have  things  ready,  or  to  place  the  patient  quickly 
and  comfortably  in  the  desired  position. 

Illumination  of  Cavities. — In  conditions  when  it  is 
desirable  to  get  a  clear  picture  of  the  interior  of  a  cavity, 
such  as  the  vagina,  the  bladder,  the  posterior  nares,  the 
posterior  chamber  of  the  eye,  etc.,  a  brighter  illumination 
may  be  obtained  by  reflecting  an  artificial  light  from  a  small 
mirror  directly  on  to  the  spot.  The  mirror  in  general  use 
is  most  conveniently  worn  on  the  forehead  of  the  operator, 
to  which  it  is  attached  by  a  strap  and  buckle;  it  is  usually 
known  as  the  head-mirror  (Fig.  55,  p.  242) .  With  the  light 
in  a  suitable  position  an  intensely  bright  light  is  focused 
from  the  mirror  on  to  the  area  to  be  examined,  and  re- 
flected back  from  the  spot  so  illuminated.  Under  suitable 
circumstances  sunlight  may  be  used,  but  usually  an  arti- 
ficial light  is  more  satisfactorily  adjusted.  When  an  arti- 
ficial light  is  used,  the  room  must  be  thoroughly  darkened; 
the  light  is  held  opposite  the  operator  behind,  and  somewhat 
to  one  side  of,  the  part  to  be  examined,  at  such  an  angle 
that  the  rays  are  focused  by  the  mirror  and  thrown  directly 
on  the  desired  spot.  The  head-mirror  is  provided  with  a 
minute  opening  in  the  center,  through  which  the  examina- 
tion can  be  made  if  preferred. 

EXAMINATION  OF  ORGANS   OF  SPECIAL  SENSE 
For  the  proper  examination  of  the  organs  of  the  special 
senses  a  darkened  room,  with  artificial  light  and  reflecting 
mirror,  is  practically  essential. 

Examination  of  the  Eye. — The  eye  is  examined  in  order 
to  determine  irregularities  of  vision,  such  as  myopia 
(near-sightedness),  hypermetropia  (far-sightedness),  or 
astigmatism  (defective  refraction),  and  to  ascertain  the 


240 


OBSERVATION   AND   EXAMINATION 


condition  of  those  parts  of  the  organ  of  sight  contained 
in  the  interior  of  the  eye.  This  includes  the  retina,  which 
is  the  expanded  end  of  the  optic  nerve,  forming  a  fine  net- 
work round  the  internal  chamber  of  the  eye,  and  the 

crystalline  lens,  which  is 
suspended  immediately  be- 
hind the  iris. 

The  interior  of  the  eye 
is  examined  through  the 
pupil,  the  opening  behind 
the  transparent  portion  of 
the  conjunctiva,  which  be- 
comes smaller  when  ex- 
posed to  the  light,  owing 
to  the  drawing  together  of 
the  iris,  or  curtain  of  the 
eye.  To  overcome  this, 
when  careful  examination 
of  the  interior  of  the  eye 
is  necessary,  one  or  two 
drops  of  a  solution  con- 
taining a  mydriatic  are 
applied  between  the  lids 
an  hour  or  two  previously. 
A  mydriatic  is  a  drug 
which  has  the  effect  of  di- 
lating the  pupil  by  con- 
tracting and  paralyzing 
certain  muscles  of  the  iris. 

Fig.  54.— Loring's  ophthalmoscope.  The  mydriatic  usually  em- 
ployed is  atropin  (the  al- 
kaloid of  belladonna);  the  usual  strength  used  is  either 
2  grains  or  4  grains  to  the  ounce.  Generally,  2  drops 
are  ordered,  one  under  the  upper  lid  and  one  under  the 
lower. 

The  effect  of  atropin  is  slow  in  passing  away;  usually 
the  effect  lasts  the  greater  part  of  a  week,  during  which 
time  the  eye  cannot  be  used  for  reading,  writing,  and 
similar  occupations.  Where  it  is  not  considered  neces- 
sary to  keep  the  eye  at  rest  for  so  long  a  time,  homa- 


EXAMINATION   OF   ORGANS   OF   SPECIAL  SENSE      241 

tropin  is  used  instead.  Homatropin  is  a  derivative 
of  atropin,  with  a  milder  action  and  more  quickly  tran- 
sitory effect.  Some  discomfort,  usually  a  dryness  of 
the  throat  or  nose,  is  sometimes  experienced  by  people 
as  the  result  of  atropin  eye  drops.  This  may  be  dimin- 
ished by  care  in  not  applying  more  than  the  required 
number  of  drops,  and  by  directing  the  patient  to  keep 
the  nose  held  and  the  eye  closed  for  a  few  moments 
after  the  application.  The  tears  excited  will  then  flow 
over  the  cheek,  instead  of  into  the  nose  by  the  lacrimal 
canal,  and  can  be  removed  with  a  handkerchief.  The 
patient  sits  opposite  the  operator,  the  light  behind  his 
head  on  the  side  of  the  eye  to  be  examined.  For  accurate 
examination  an  instrument  known  as  an  ophthalmoscope 
is  used.  It  consists  of  a  small  reflecting  mirror  with  an 
opening  in  the  middle,  through  which  the  examiner  looks. 
The  mirror  is  in  an  oblong  metal  plate  fitted  to  a  convenient 
handle;  to  the  plate  are  attached  small  lenses  of  varying 
refractive  power,  which  can  be  revolved  in  front  of  the 
small  opening  in  testing  the  refraction  of  the  eye.  A 
crystal  biconvex  lens  is  also  constantly  used,  either  in 
place  of  a  mirror,  to  illuminate  the  eye,  or  in  testing  the 
refraction. 

In  many  cerebral  conditions,  and  in  accidents  involving 
portions  of  the  brain,  an  examination  of  the  internal  cham- 
ber of  the  eye  is  of  considerable  diagnostic  importance. 
In  these  conditions  the  examination  is,  of  course,  made  with 
the  patient  in  the  recumbent  position. 

Examination  of  the  Ear. — The  ear  is  examined  for  the 
purpose  of  obtaining  a  picture  of  the  tympanum  or  drum, 
the  delicate  membrane  being  between  the  external  audi- 
tory canal  and  the  chamber  of  the  middle  ear,  upon  the  in- 
tegrity of  which  we  depend  for  our  hearing.  Small  highly 
polished  specula,  usually  of  silver,  in  shape  like  a  little 
funnel  are  used.  The  outer  ear  is  drawn  slightly  upward 
and  backward,  in  order  to  straighten  the  auditory  canal; 
the  speculum  is  placed  in  the  opening,  and  illuminated 
with  the  bright  light  reflected  from  the  head-mirror. 
Through  the  speculum  applications  can  be  made  to  the 
drum,  and  operations,  such  as  puncturing  the  drum,  per- 


242 


OBSERVATION  AND   EXAMINATION 


formed.  The  patient  sits,  of  course,  with  the  ear  opposite 
the  operator. 

Examination  of  the  Nose. — Similar  small  specula  are 
also  used  in  examining  the  nose — either  the  nostrils 
(nares)  or  the  posterior  nares,  the  small  cavity  lying  be- 
tween the  nose  and  the  throat.  The  specula  dilate  the 
opening  and  help  to  illuminate  the  cavity.  In  passing 
any  instrument  into  the  posterior  nares  the  tip  of  the  nose 
is  pushed  upward  and  the  instrument  passed  directly  back- 
ward into  the  small  opening  thus  exposed. 

Examination  of  the  Throat. — For  an  examination  of  the 
throat  a  tongue  depressor  and  applicators  of  a  suitable 


Fig.  55. — Laryngoscopy,  showing  the  mirror  being  introduced,  and 
also  the  relative  position  of  the  patient  and  examiner  and  the  posi- 
tion of  the  Light  (Morrow). 

size  are  necessary.  The  patient  sits  directly  opposite 
the  operator,  his  back  to  the  light;  an  artificial  light  and 
head-mirror  are  always  advisable.  Tongue-depressors 
are  flat  instruments,  made  of  metal  or  glass;  any  small 
flat  body,  such  as  a  paper-knife  or  the  handle  of  a  spoon, 
serves  the  purpose.  In  hospital  work  small,  flat  pieces 
of  smooth  wood  are  commonly  used,  especially  in  the  out- 
patient department,  and  can  be  discarded  after  use,  if 


EXAMINATION   OF   ORGANS   OF   SPECIAL  SENSE      243 

advisable,  without  much  expense.  Clothes-pins  divided 
in  half  are  frequently  used  as  cheap  and  convenient  tongue 
depressors.  Wooden  applicators  resembling  long  tooth- 
picks are  generally  used,  and  burnt  after  use.  The 
applicators  are  mounted,  with  their  strands  of  absorbent 
cotton  as  already  described;  they  may  be  mounted  and 
put  up  in  packets  of  a  dozen  and  sterilized  like  other 
dressings.  A  second  small  mirror  mounted  on  a  handle 
is  passed  to  the  back  of  the  throat,  in  order  to  obtain  a 
picture  of  the  larynx  (laryngoscopy) . 


Fig.  56. — Inflation  by  Politzcr's  method  (Morrow). 

For  a  throat  examination  a  basin,  towel,  and  glass  of 
warm  water  should  be  at  hand.  In  sensitive  patients 
reflex  vomiting  may  be  excited  by  the  pressure  on  the 
tongue  or  the  touch  of  the  applicator.  Applicators  are 
also  frequently  applied  to  the  throat  in  the  form  of  sprays. 

The  Eustachian  catheter  is  a  small,  fine,  hollow  instru- 
ment, used  to  dilate  the  eustachian  tube,  i.  e.,  the  passage 
leading  from  the  back  of  the  throat  to  the  middle  ear, 
or  air-space  immediately  behind  the  drum.  Generally, 
it  is  not  lubricated,  glycerin  having  too  astringent  an  effect 


244  OBSERVATION   AND    EXAMINATION 

upon  the  mucous  membrane,  and  the  taste  of  oil  or  soap 
being  objectionable  to  the  patient.  It  is  usually  wet  with 
hot  water  before  passing. 

Politzer's  bag  is  an  apparatus  frequently  used  in  throat 
treatment.  Its  use  is  to  dilate  the  Eustachian  tubes  by 
suddenly  forcing  through  them  a  volume  of  air.  It  is  a 
large  rubber  ball  filled  with  air,  and  provided  with  a  short 
nozzle  of  bone  or  hard  rubber.  The  tip  of  the  nozzle  is 
introduced  into  one  nostril;  the  patient  is  then  directed 
to  swallow  a  sip  of  water;  as  he  swallows,  the  bag  is  sharply 
squeezed  and  the  air  prevented,  by  the  act  of  swallowing, 
from  escaping  out  of  the  mouth  or  entering  the  respiratory 
passages,  is  forced  through  the  Eustachian  tubes  (Fig.  56). 

OBSERVATION  OF  THE  SKIN 

Any  abnormal  appearance  of  the  skin,  general  or  local, 
is  probably  of  diagnostic  value. 

Pallor. — Abnormal  pallor  of  the  skin  and  mucous  mem- 
brane may  be  due  to  deficient  circulation  from  disturbance 
of  the  heart's  action,  as  in  fainting,  to  contraction  of  the 
superficial  blood-vessels,  as  in  exposure  to  cold,  to  condi- 
tions in  which  the  blood  is  deficient  in  coloring,  as  in  the 
various  anemias. 

Cyanosis,  or  bluenessof  the  skin  and  mucous  membranes, 
results  when  the  blood  is  not  sufficiently  oxidized.  It  may 
be  caused  by  obstruction  in  the  respiratory  passages  or 
organs  (see  Respiration),  by  conditions  causing  congestion 
of  the  venous  circulation,  as  in  valvular  heart  disease,  or 
from  failure  of  the  nerve-centers  controlling  the  respira- 
tion and  the  action  of  the  heart,  as  in  conditions  of 
collapse.  Cyanosis  is  relieved  in  several  ways:  (1)  By  the 
administration  of  oxygen;  (2)  indirectly  by  venesection, 
which  relieves  the  venous  congestion;  (3)  by  the  subcu- 
taneous injection  of  one  to  two  points  of  normal  salt 
solution,  which  increases  the  volume  of  the  blood,  thereby 
stimulating  the  circulation,  and  through  the  circulation, 
the  vital  centers. 

Color. — Some  diseases  are  characterized  by  changes  in 
the  color  of  the  skin.  In  jaundice  the  tissues  are  stained 
yellow,  from  the  presence  of  bile  in  the  blood.  The  discolora- 


OBSERVATION   OF   THE   SKIN  245 

tion  includes  the  conjunctiva  (the  transparent  covering  of 
the  eye),  in  which  delicate  membrane  the  yellow  tinge  first 
appears.  Jaundice  is  a  prominent  symptom  in  the  acute 
infectious  fever  known  as  yellow  fever.  Any  conditions 
that  may  cause  obstruction  to  the  bile-ducts  may  be  associ- 
ated with  jaundice,  such  as  catarrhal  conditions,  inflam- 
mation or  disease  of  the  liver  or  gall-bladder,  obstruction 
by  gall-stones,  pressure,  as  from  cancer,  etc. 

Anemia. — Simple  anemia  is  characterized  by  pallor 
of  the  skin  and  of  the  mucous  membrane,  especially 
noticeable  on  the  lipse  and  the  conjunctiva.  The  grave 
form  of  anemia,  known  as  pernicious  or  malignant  anemia, 
is  characterized  by  a  lemon  hue  of  the  skin  and  mucous 
membranes,  the  eyes  remaining  clear.  The  discoloration 
is  permanent,  and  the  disease  is  considered  incurable. 

Chlorosis,  or  green  sickness,  is  the  name  given  to  a  form 
of  essential  anemia  occurring  chiefly  in  girls  and  young 
women,  in  which  the  skin  assumes  a  greenish  hue.  The 
disease  yields  to  treatment,  including  a  nourishing  diet, 
iron,  rest,  fresh  air,  and  good  hygiene. 

A  temporary  local  bronzing  of  the  skin,  occurring  as 
tawny  patches,  chiefly  on  the  exposed  surfaces  of  the  body, 
is  common  in  pregnancy. 

Pigmented  patches  of  a  deeper  shade  of  bronze  on  the 
skin  and  on  the  mucous  membranes,  especially  of  the 
mouth,  is  usually  associated  with  Addison's  disease,  a 
fatal  affection  due  to  disease  of  the  suprarenal  glands. 

Rashes  or  cutaneous  eruptions  are  inflammatory  condi- 
tions of  the  skin  from  various  causes.  They  may  be  due 
to  the  action  of  toxins,  to  the  use  of  certain  drugs,  to  local 
irritations  or  inflammations,  to  animal  or  vegetable 
parasites,  or  to  subcutaneous  hemorrhages.  Rashes  may 
be  diffuse  or  circumscribed,  and  present  varied  character- 
istic appearances,  to  describe  which  the  following  terms 
are  used: 

Erythema. — An  erythematous  rash  giving  the  skin  a 
bright-red  appearance,  like  a  diffuse  blush.  In  some  in- 
stances, on  close  examination,  the  rash  appears  to  be 
formed  of  minute  scarlet  points  in  close  proximity.  Ery- 
thematous rashes  of  this  variety  are  known  as  punctiform. 


246  OBSERVATION   AND    EXAMINATION 

They  are  characteristic  of  scarlet  fever,  erysipelas,  German 
measles,  and  many  accidental  rashes. 

Macule. — A  macule  appears  as  a  spot  not  raised  above 
the  surface  of  the  skin.  A  rash  occurring  in  unelevated 
spots,  either  general  or  in  isolated  parts  of  the  body,  is 
described  as  macular.  In  inflammatory  conditions  the 
spots  are  red;  in  other  conditions  they  may  be  brown 
(freckles  or  lentigo},  yellowish,  or  white. 

Papule. — A  small  solid  spot  elevated  above  the  surface 
of  the  skin,  usually  pink  or  red  in  color,  is  known  as  a 
papule.  Papules  may  occur  in  isolated  areas,  as  in  the 
typhoid  rash,  or  distributed  generally  all  over  the  body, 
as  in  the  rashes  of  measles,  small-pox,  etc.  In  many  in- 
stances papules  become  vesicular  or  pustular.  Slightly 
convex  papules  are  described  as  lenticular,  from  their 
resemblance  to  the  form  of  a  lens  (example,  the  typhoid 
spot).  (See  also  p.  727,  Rashes  of  Eruptive  Fevers.) 

Tubercle. — A  solid  elevation  or  patch,  larger  than  a 
papule,  is  described  as  a  tubercle  or  nodule.  Characteristic 
tubercles  are  found  in  syphilis,  barber's  itch,  lupus,  etc. 
Tubercles  vary  in  size  from  a  "  split-pea  to  a  hazel-nut  " 
(Gould). 

A  vesicle  is  a  blister.  An  eruption  occurring  in  small 
blisters  containing  clear  fluid  (serum)  is  described  as 
vesicular.  Commonly,  the  vesicle  begins  as  a  papule. 
The  larger  vesicles  are  described  as  blebs. 

Pustule. — Vesicles  containing  pus  are  known  as  pustules. 
They  usually  occur  first  as  papules  or  simple  vesicles; 
the  clear  serum  changes  to  a  milky  exudate,  formed  of 
serum  and  white  corpuscles,  which  may  shortly  become 
true  pus.  Small-pox  is  characterized  by  a  pustular  rash. 
The  vesicles  in  chicken-pox,  more  rarely  the  papules  of 
measles,  may  also  become  pustular,  especially  if  infected 
by  scratching. 

Wheals  or  Pomphi. — A  wheal  resembles  a  papule,  but 
is  evanescent  and  characterized  by  excessive  itching. 
They  may  be  red,  or  show  a  white  papule  on  a  reddened 
skin.  A  rash  consisting  of  crops  of  wheals  is  characteristic 
of  urticaria;  wheals  are  also  produced  by  the  bites  of 
insects. 


OBSERVATION   OF  THE   SKIN  247 

Petechia. — Petechise  are  small  purple  points  occurring 
under  the  skin,  the  results  of  minute  hemorrhages.  The 
rash  is  often  described  as  a  hemorrhagic  rash.  Such 
rashes  are  characteristic  of  purpura,  typhus  fever,  cerebro- 
spinal  meningitis,  and  may  also  occur  in  severe  forms  of 
scurvy  and  the  malignant  varieties  of  scarlet  fever, 
measles,  and  small-pox.  A  purplish  discoloration  of  the 
skin  in  larger  patches,  caused  by  profuse  subcutaneous 
hemorrhage,  is  known  as  ecchymosis  (p.  613). 

Scales. — A  scaly  or  squamous  eruption  is  due  to  the 
separation  of  the  upper  layers  of  the  epithelium.  Many 
forms  of  skin  disease  are  characterized  by  the  formation 
of  scales;  the  formation,  character,  and  distribution  of 
the  scales  determine  the  diagnosis.  Commonly,  the  scal- 
ing is  associated  with  some  inflammatory  condition  of  the 
skin.  The  presence  of  flaky  scales  on  the  body  may  be 
due  to  desquamation  following  one  of  the  eruptive  fevers, 
especially  scarlet  fever. 

In  certain  conditions  the  skin  has  a  swollen  appear- 
ance. This  may  be  local,  occurring  in  strictly  circum- 
scribed areas,  or  extensive,  involving  a  large  portion  of 
the  body,  or  generally  distributed  over  all  the  body. 
Such  swellings  are  described  in  the  following  terms: 

Induration. — The  tissues  feel  hard,  solid,  and  resistant. 
Separate  indurated  swellings  are  commonly  due  to  exuda- 
tion from  inflammatory  processes.  The  swelling  may 
become  softer  and  gradually  disappear  as  the  inflammatory 
processes  are  absorbed,  a  process  known  as  resolution; 
or  suppuration  may  occur,  and  we  speak  of  the  mass 
breaking  down. 

General  induration  of  the  skin  occurs  typically  in  the 
disease  known  as  myxedema.  The  appearance  generally 
suggests  dropsy,  but  the  skin  feels  solid  or  resistant,  and 
does  not  pit  on  pressure. 

Brawny. — -"Extensive  local  indurations  involving  deeper 
tissues  are  spoken  of  as  brawny.  Brawny  swellings  are 
frequently  due  to  cellulitis.  A  brawny  condition  of  the 
extremities  involving  the  muscles  is  common  in  scurvy. 

Edema  or  Dropsy.— An  edematous  swelling  is  due  to  an 


248  OBSERVATION   AND   EXAMINATION 

accumulation  of  lymph  fluid  derived  from  the  blood-stream 
in  the  cellular  tissues  (p.  711). 

A  swelling  due  to  edema  may  be  readily  indented  by 
pressure,  the  indentations  remaining  after  the  pressure  is 
removed.  The  skin  is  said  to  pit  on  pressure.  Edema  is 
a  characteristic  symptom  in  valvular  heart  disease,  acute 
nephritis,  and  anemia. 

In  the  rare  condition  known  as  cutaneous  emphysema, 
air  is  present  in  the  cellular  tissues.  The  skin  will  pit 
on  pressure,  but  the  indentation  disappears  as  soon  as 
pressure  is  removed.  On  pressure,  a  crackling  noise  is 
heard  over  the  area;  the  condition  is  due  to  an  escape  of 
air  or  gas  into  the  tissues  caused  by  the  rupture  of  such 
an  organ  as  the  lungs  or  stomach,  etc.  The  rupture  may 
result  from  a  wound  or  from  disease  associated  with  ulcera- 
tion. 

Hypertrophy  and  Atrophy. — Changes  in  the  structure 
of  an  organ  due  to  disease  are  called  morbid  changes. 

Enlargement  of  any  organ  or  tissue  due  to  morbid 
changes  is  called  hypertrophy.  In  some  conditions  we 
may  have  extensive  areas  hypertrophied.  The  immense 
swelling  of  the  skin  and  cellular  tissues  of  the  lower  extrem- 
ities in  elephantiasis  is  an  example  of  hypertrophy. 

A  wasting  of  any  tissue  or  organ  resulting  in  a  lessening 
of  the  size  is  described  as  atrophy.  This  may  infect  an 
entire  limb,  as  in  some  forms  of  paralysis,  where  the  proc- 
esses of  nutrition  are  less  active  than  in  other  parts  of  the 
body,  with  the  result  that  the  limb  appears  shrunken  and 
withered. 

EXAMINATION   OF  THE  BLOOD 

The  examination  of  a  patient  includes  the  examination 
of  the  excreta,  vomitus,  and  sputum  (see  following  chap- 
ter), and,  usually,  the  microscopic  examination  of  any 
abnormal  discharge.  This  latter  is  accomplished  by 
taking  a  culture  (p.  527). 

Under  all  circumstances,  at  the  present  day,  it  is  also 
the  custom  to  examine  a  specimen  of  the  blood  of  the 
patient,  its  condition  being  very  frequently  of  diagnostic 
importance.  In  many  conditions  and  in  diseases  affecting 


EXAMINATION   OF  THE   BLOOD 


249 


vitality  the  composition  of  the  blood  is  altered.  It  may 
be  altered  in  relation  to  the  proportion  of  fluids  and  solids, 
or  in  the  proportion  of  the  different  solids  to  each  other;  it 
may  also  contain  extraneous  substances,  such  as  urea, 
bile,  the  bacteria  of  disease,  or  certain  parasites. 

The  methods  employed  for  examining  the  blood  are 
the  blood-count,  the  blood-smear,  and  in  special  cases  the 
blood-culture. 

The  blood-count  is  used  for  the  enumeration  of  the 
corpuscles. 


Fig.  57. — Thoma-Zeiss  hemocytometer:  a,  Slide  used  in  counting; 
b,  sectional  view;  d,  red  pipet;  e,  white  pipet. 


A  small  area  of  the  skin  surface,  usually  the  tip  of  the 
finger,  is  selected,  washed  with  sterile  soap  and  water, 
and  sponged  with  alcohol.  Antiseptics  are  not  used, 
since,  unless  completely  removed  before  the  skin  is  pricked, 
they  would  coagulate  the  albumin  in  the  blood.  After 
cleansing,  the  spot  is  lightly  pricked  with  a  small  sterile 
knife  and  a  drop  of  blood  drawn  up  into  a  special  glass 
tube.  This  tube  is  known  as  a  melangeur,  and  consists 
of  a  fine  capillary  tube,  one  part  of  which  is  expanded  into 
a  small  chamber  with  a  capacity  of  100  cm.  The  drop  of 
blood  is  sucked  up  to  a  mark  on  the  tube;  the  point  of  the 
tube  is  wiped  clean,  and  a  certain  quantity  of  a  special 


250  OBSERVATION   AND   EXAMINATION 

diluting  fluid  is  drawn  into  the  melangeur,  with  which 
the  blood  is  thoroughly  shaken  up.  It  is  then  ready  for 
examination  under  the  microscope.  A  special  slide  is 
used,  usually  that  known  as  the  Thoma-Zeiss  hemo- 
cytometer.  This  is  a  glass  slide,  in  the  center  of  which  a 
minute  cell  is  ground  out;  the  floor  of  the  cell  under  the 
microscope  is  seen  to  be  marked  off  into  400  squares 
of  equal  size.  The  diluted  drop  is  placed  in  the  cell,  the 
corpuscles  sink  to  the  bottom,  and,  under  the  microscope, 
appear  grouped  in  the  different  squares,  where  they  can 
be  readily  counted. 

A  different  diluting  fluid  is  used  according  to  whether 
it  is  desired  to  enumerate  the  red  or  the  white  corpuscles. 
In  the  latter  case  a  fluid  is  used  in  which  the  red  cells 
disappear. 


Fig.  58. — Cells  of  blood:  a,  Colored  blood-corpuscles  seen  on  the 
flat;  b,  on  edge;  c,  in  rouleaux  (Leroy). 

We  remember  that  in  normal  conditions  the  average 
number  of  red  corpuscles  (erythrocytes)  in  the  blood  is 
5,000,000  to  the  cubic  millimeter,  and  of  white  corpuscles 
(leukocytes)  from  5000  to  10,000;  in  other  words,  about 
one  white  cell  to  500  red  cells.  Certain  transitory  condi- 
tions may  affect  this  proportion  in  health;  in  disease  it  may 
be  considerably  altered.  In  almost  all  forms  of  anemia, 
either  essential  or  secondary,  as  following  a  severe  hem- 
orrhage, the  red  corpuscles  are  markedly  diminished  in 
number.  Except  in  certain  rare  forms  of  anemia  their 
shape  is  not  altered.  Red  corpuscles  are  all  of  one  variety, 
shaped  like  little  biconcave  coins;  on  the  other  hand,  there 
are  several  forms  of  white  corpuscles.  They  are  easily 
distinguished  from  the  red  corpuscles  by  their  lack  of 


EXAMINATION   OF   THE    BLOOD 


251 


color,  their  irregular  shape,  and  the  presence  of  a  more 
solid  central  portion  known  as  a  nucleus.  Unlike  the 
red  cells,  the  white  cells  possess  a  certain  amount  of  inde- 
pendent activity,  by  which  they  can  migrate  from  one 
part  of  the  body  to  another  and  get  outside  the  capillary 
blood-vessels.  The  movements  are  those  common  to 
protoplasm,  of  which  substance  the  white  cells  are  formed, 
and  are  called  ameboid  movements. 

In  normal  blood  four  varieties  of  white  cells  are  observed : 

1.  Small  lymphocytes,  small  cells  with  a  relatively  large 
nucleus;  they  form  from  25  to  35  per  cent,  of  all  leukocytes. 

2.  Large  lymphocytes,  similar  cells,  larger  in  size,  with 
relatively  smaller  nucleus:  form  5  to  10  per  cent,  of  all 
blood-corpuscles. 


Fig.  59. — Various  forms  of  leukocytes:  a,  Small  lymphocyte;  b, 
large  lymphocyte;  c,  polymorphonuclear  neutrophile;  d,  eosinophile 
(Leroy). 


3.  Polymorphonuclear  neutrophiles:  the  nucleus  is  divided 
into  two  and  sometimes  more,  and  the  basic  structure,  the 
protoplasm,  is  covered  with  granules:  form  60  to  70  per 
cent,  of  the  white  cells. 

4.  Eosinophiles:  so  called  from  their  affinity  for  eosin 
(an  acid  stain  used  in  examining  cells),  resemble  closely 
the  third  variety:  form  1  to  4  per  cent,  of  the  white  cells. 

Other  varieties  may  be  found  in  certain  diseases  resemb- 
ling one  or  other  of  the  above,  but  with  special  character- 
istics. In  disease  the  total  proportion  of  white  corpuscles 
in  the  blood  may  be  decreased — leukopenia;  or  increased, 
leukocytosis ;  or  one  variety  may  be  increased  out  of  pro- 
portion to  the  others. 

Leukocytosis  occurs  in  a  large  variety  of  circumstances, 
the  increase  being  especially  in  the  polymorphonuclear 
cells.  It  occurs  in  all  infectious  diseases,  such  as  pneu- 


252  OBSERVATION   AND    EXAMINATION 

monia,  scarlet  fever,  etc.,  with  a  few  exceptions:  in  inflam- 
matory or  suppurative  conditions,  as,  for  example,  in 
appendicitis  or  the  formation  of  an  abscess;  in  other 
toxic  conditions,  such  as  uremia  and  gout;  following  severe 
hemorrhage;  as  an  accompanying  symptom  in  perforation; 
in  many  malignant  affections  and  other  conditions. 

Leukopenia  is  a  special  characteristic  of  a  few  infectious 
diseases,  especially  typhoid  fever,  malaria,  and  miliary 
tuberculosis.  It  is  also  observed  in  pernicious  anemia  and 
conditions  of  extremely  low  vitality. 

Leukemia  is  a  disease  in  which  the  number  of  white 
cells  are  persistently  increased.  In  leukemia  the  lympho- 
cytes are  enormously  increased,  while  in  some  diseases 
caused  by  animal  parasites  (filariasis,  trichiniasis,  etc.), 
in  some  skin  affections  (eczema,  psoriasis,  etc.),  and  also  in 
other  conditions,  the  eosinophiles  are  increased  relatively 
or  absolutely. 

From  the  above  it  is  easy  to  gather  the  diagnostic  im- 
portance of  an  accurate  count  of  the  different  white  cells 
(usually  called  a  differential  count),  especially  during  the 
course  of  a  disease  characterized  by  either  an  increase  or 
decrease  in  the  normal  number.  For  example,  in  typhoid 
fever  we  look  for  a  low  count  of  the  white  cells ;  an  increase 
in  their  number  suggests  a  complication  associated  with 
leukocytosis,  such  as  perforation  or  some  inflammatory 
condition,  and  may  be  a  very  important  aid  to  diagnosis 
where  the  physical  symptoms  are  obscure.  A  low  count 
of  white  cells  in  infections  usually  characterized  by  leuko- 
cytosis frequently  is  considered  a  sign  that  the  patient's 
resistance  is  low,  and  the  treatment  is  modified  accordingly. 

In  studying  the  forms  of  the  different  varieties  of 
blood-corpuscles  the  blood-smear  is  used. 

Blood-smear. — To  take  a  smear  of  blood  the  tip  of  the 
finger  is  prepared  as  already  described,  pricked,  and  a 
drop  of  the  blood  received  on  a  perfectly  clean  cover-glass, 
which  is  immediately  covered  with  a  second,  the  corners 
of  one  glass  being  placed  across  the  straight  margin  of  the 
other.  The  two  glasses  are  pressed  together,  causing  the 
drop  to  spread  evenly  over  the  surface,  and  then  drawn 
apart  and  dried  in  the  air.  Sterile  forceps  should  be  used 


EXAMINATION    OF   THE   BLOOD 


253 


in  the  manipulation  of  the  glasses,  to  prevent  the  risk 
of  contamination  from  the  touch  of  the  fingers.  Sub- 
sequently the  smear  is  fixed  by  heat,  and  stained  according 
to  the  requirements  of  the  examination  (p.  398). 

The  blood  culture  is  used  when,  for  diagnostic  purposes, 
it  is  necessary  to  ascertain  the  presence  of  certain  patho- 
genic bacteria  in  the  blood.  Under  strict  aseptic  pre- 
cautions an  exploring  needle  is  introduced  under  the  skin 


Fig.  60. — Von  Fleischl's  hernoglobinometer :  a,  Stand;  b,  narrow 
wedge-shaped  piece  of  colored  glass  fitted  into  a  frame,  c,  which 
passes  under  the  chamber;  d,  hollow  metal  cylinder,  divided  into 
two  compartments,  which  hold  the  blood  and  water;  e,  plaster-of- 
Paris  plate  from  which  the  light  is  reflected  through  the  chamber; 
/,  screw  by  which  the  frame  containing  the  graduated  colored  glass 
is  moved;  g,  capillary  tube  to  collect  the  blood;  h,  pipet  for  adding 
the  water;  i,  opening  through  which  may  be  seen  the  scale  indicating 
percentage  of  hemoglobin. 

directly  into  one  of  the  veins  of  the  forearm.  The  vein 
is  previously  distended  by  applying  a  bandage  tightly 
round  the  upper  arm.  (See  p.  527.)  The  blood,  usually 
about  2  drams,  is  caught  in  a  sterile  glass  tube  and  im- 
mediately transferred  to  tubes  containing  the  necessary 
culture-media.  The  cultures  are  then  developed  in 
the  laboratory  and  studied  under  the  microscope.  The 
puncture  must  be  carefully  dressed  under  aseptic  pre- 
cautions. 


254  OBSERVATION  AND   EXAMINATION 

The  blood  from  suspected  cases  of  typhoid  fever  is  put 
to  a  test  known  as  the  Widal  test  (described  on  p.  402). 
The  blood  for  the  test  is  usually  taken  from  the  tip  of  the 
finger,  smeared  on  small  pieces  of  specially  prepared  white 
paper,  and  allowed  to  dry  in  the  air. 

Hemoglobin. — The .  estimation  of  the  percentage  of 
hemoglobin  (red  coloring-matter)  in  the  blood  is  also 
usually  a  matter  of  routine  work.  The  hemoglobin  is 
contained  in  the  red  corpuscles,  to  which  it  gives  their 
red  color.  Various  special  instruments  are  used  for  esti- 
mating hemoglobin.  In  one  very  generally  used  (Fleischl's) 
the  drop  of  blood,  spread  out  on  a  small  slide  of  clear  glass, 
is  compared  under  an  artificial  light  with  a  piece  of  red 
glass  graduated  to  the  different  shades  of  red  given  to  the 
blood  by  the  proportion  of  hemoglobin.  The  red  glass  is 
connected  with  a  scale  in  such  a  manner  that  the  different 
shades  are  registered  as  percentages,  the  100  per  cent, 
being  the  same  shade  of  red  as  blood  with  100  per  cent, 
hemoglobin. 

In  private  practice  the  Tallquist  method  is  frequently 
employed  on  account  of  its  convenience.  It  consists  of  a 
booklet  containing  filter-paper  and  a  colored  plate  in 
ten  shades  of  red,  representing  the  color  of  the  blood  with 
the  percentages  of  hemoglobin  from  100  to  10.  The  filter- 
paper  is  stained  with  a  drop  of  blood  and  then  compared 
with  the  colored  plate. 

HISTORY-TAKING 

In  the  smaller  hospitals,  where  there  is  no  resident 
doctor,  it  frequently  falls  to  the  chief  nurse  to  take  the 
history  of  fresh  cases,  especially  when  the  patients  are 
children  or  in  an  unconscious  condition,  where  all  the 
information  must  be  gathered  from  the  friends.  A  sys- 
tematic routine  of  questions  is  necessary,  that  no  point 
should  be  overlooked. 

First:  The  first  details  ascertained  should  be  the  name,, 
age,  sex,  race,  and  social  status  (married  or  single)  of  the 
patient,  his  birthplace,  occupation,  and  present  address. 
For  convenience  in  hospitals  the  name  and  address  of  his 
nearest  relative  should  be  also  noted,  and,  if  a  non-resident 


HISTORY-TAKING  255 

in  the  town,  the  name  and  address  of  an  acquaintance 
resident  in  town. 

Second :  Next  in  order  is  his  family  history :  whether  his 
parents  are  alive,  and  if  not,  the  cause  and  other  details 
of  their  deaths;  the  number  of  brothers  and  sisters,  and 
the  enumeration  of  any  illnesses  to  which  they  have  been 
subject,  and  the  cause  of  any  deaths  that  may  have  oc- 
curred. The  presence  in  the  family  of  any  manifesta- 
tions of  insanity,  tuberculosis,  cancer,  or  organic  disease. 

Third:  Following  the  family  history  comes  the  former 
health  record  of  the  patient.  He  should  be  minutely  ques- 
tioned as  to  any  former  illnesses,  especially  the  infectious 
illnesses  common  in  childhood,  and  rheumatism,  which 
is  frequently  followed  by  a  tendency  to  organic  heart 
lesions  and  other  manifestations. 

Fourth :  The  health  record  of  the  patient  leads  naturally 
to  the  history  of  the  present  illness.  As  far  as  possible  this 
should  be  written  down  in  the  words  of  the  patient,  and 
considerable  ingenuity  must  be  exercised  to  elicit  informa- 
tion without  giving  leading  questions  which  may  produce 
biased,  and  often  misleading,  answers  from  the  frequently 
bewildered  patient.  The  date  of  the  apparent  onset  and 
the  symptoms  first  noticed  must  be  first  noted,  and  then 
the  progress  of  the  illness  and  the  order,  when  possible, 
in  which  divers  symptoms  have  manifested  themselves. 
Judicious  questioning  should  elicit  such  facts  as  loss  of 
sleep  and  appetite,  cough,  evening  feverishness,  attacks 
of  shivering,  excessive  perspiration,  and  some  description 
of  any  expectorations  or  vomited  matter. 

To  take  a  history  adequately  requires  practice,  patience, 
and  tact.  A  good  history  is,  however,  one  of  the  best  aids 
to  the  clinical  study  of  disease,  and  it  is  well  worth  while 
to  acquire  the  necessary  skill  to  write  reliable  and  infor- 
mative histories  where  such  history  falls  in  the  routine  of 
a  nurse's  work. 


CHAPTER  VII 

EXAMINATION  OF  VOMITUS,  SPUTUM,  AND  EX- 
CRETA 

THE  VOMITUS 

BY  vomitus  we  understand  the  contents  of  the  stomach 
which  have  been  ejected.  All  vomited  matter  should 
invariably  be  carefully  inspected.  The  composition  of 
the  vomitus  itself,  its  odor  and  color,  are  valuable  indica- 
tions of  the  state  of  the  digestion  and  the  condition  of 
the  upper  part  of  the  alimentary  tract,  while  the  character 
of  the  vomiting,  the  time  at  which  it  occurs,  whether 
soon  after  the  meal  or  toward  the  end  of  digestion,  and 
the  symptoms  which  accompany  the  act,  help  to  deter- 
mine the  cause  of  the  vomiting.  In  the  case  of  poisoning 
the  vomitus  is  of  important  diagnostic  value  and  should 
always  be  saved  for  examination.  Vomitus,  when  re- 
quired for  examination,  should  be  covered  to  protect  it 
from  air  and  dust,  but  not  otherwise  disturbed.  It 
should  not  be  mixed  with  a  disinfectant. 

Character  of  Vomiting. — The  simplest  form  of  vomiting 
is  a  regurgitation  or  overflow  of  food  from  the  stomach 
directly  after  it  has  been  taken.  It  is  frequently  seen  in 
infants  that  have  been  too  quickly  fed  or  that  have  taken 
too  much  food  at  one  time.  In  others  regurgitation  fre- 
quently signifies  a  stricture,  either  of  the  esophagus  or  at 
the  upper  opening  of  the  stomach. 

An  attack  of  vomiting  is  usually  preceded  by  headache, 
nausea,  distress,  and  frequently  gastric  pain.  The  act 
is  accompanied  by  retching  and  noisy  eructation  of  gas; 
the  attack  is  followed  by  a  sensation  of  relief  and  ease. 

In  certain  conditions  large  quantities  are  ejected  from 
the  stomach  at  a  time,  amounting  even  to  a  gallon  or  more. 
The  condition  is  known  as  profuse  vomiting.  Profuse 
vomiting  occurs  in  conditions  associated  with  dilatation 

856 


THE   VOMITUS  257 

of  the  stomach,  of  which  one  of  the  most  common  causes  is 
cancer  of  the  pylorus  (the  valve  at  the  lower  opening  of 
the  stomach). 

Forcible  or  projectile  vomiting  occurs  without  preliminary 
distress.  The  contents  of  the  stomach  are  forcibly  ejected 
to  considerable  distance.  The  condition  is  most  generally 
seen  in  certain  diseases  of  the  brain.  It  is  due  to  disturb- 
ance of  the  nerve-centers,  and  not  to  local  irritation. 
(See  also  Chap.  XX.) 

Consistence  of  the  Vomitus. — In  the  ordinary  attack  of 
vomiting  the  vomitus  consists  of  food  which  has  undergone 
partial  digestion.  It  has  a  sour  taste  and  odor.  Where 
vomiting  occurs  when  the  stomach  is  empty  of  food,  the 
vomitus  consists  of  small  quantities  of  green  or  yellow- 
green  fluid,  of  clear  appearance,  and  of  very  acid  taste. 
This  is  the  so-called  bilious  vomiting,  the  ordinary  ac- 
companiment of  the  bilious  attack,  sea-sickness,  and  the 
vomiting  following  anesthesia. 

In  abnormal  conditions  the  vomitus  may  contain  ab- 
normal constituents  of  special  significance.  The  most 
common  are  excessive  mucus,  blood,  pus,  and  fecal  matter. 

Excessive  mucus  in  the  vomitus  is  most  commonly  a 
chronic  condition,  associated  with  chronic  gastric  disease; 
occurring  as  an  acute  condition,  it  is  probably  due  to  poi- 
soning by  the  irritant  or  corrosive  poisons. 

Blood  in  the  vomitus  may  be  either  fresh  or  altered. 
Fresh  blood  has  the  appearance  of  streaks  mixed  with 
mucus  or  other  contents  of  the  stomach.  It  is  seen  in  the 
vomitus  caused  by  the  irritant  or  corrosive  poisons,  and 
may  also  come  from  a  lesion  in  the  upper  part  of  the  ali- 
mentary tract.  Altered  blood  is  blood  which  has  remained 
long  enough  in  the  stomach  to  be  acted  upon  by  the 
digestive  juices.  It  is  brown  in  color,  and  in  many  cases 
has  the  appearance  of  a  deposit  of  coffee-grounds.  Coffee- 
cjround  vomitus  is  common  in  ulcer  of  the  stomach  and 
cancer  of  the  stomach. 

The  vomiting  of  large  quantities  of  blood  (hematemesis) 
is  most  commonly  a  symptom  of  gastric  ulcer.  The  blood 
may  be  fresh  or  altered.  It  usually  occurs  shortly  after 
food  has  been  taken. 

17 


258      EXAMINATION   OF   VOMITUS,   SPUTUM,   EXCRETA 

Stercoraceous  or  fecal  vomitus  has  the  odor  and  appear- 
ance of  feces  and  is  unmistakable.  It  is  always  a  symp- 
tom of  grave  importance.  It  indicates  obstruction  at 
some  point  in  the  intestines,  in  consequence  of  which  the 
contents  of  the  intestines  are  regurgitated  into  the  stomach. 
(See  Treatment  of  Vomiting,  p.  713.) 

Pus  may  be  present  in  the  vomitus  as  the  result  of 
the  rupture  of  an  abscess  into  the  upper  part  of  the  ali- 
mentary tract,  as,  for  example,  into  the  pharynx  as  from 
quinsy,  or  into  the  esophagus. 

Examination  of  the  Stomach. — In  conditions  associated 
with  gastric  disorders  special  examination  of  the  stomach 
may  be  necessary. 

To  map  out  the  area  occupied  by  the  stomach  the 
patient  is  given,  while  the  stomach  is  empty,  a  Seidlitz 
powder,  or  other  effervescing  preparation;  the  stomach  is 
dilated  by  the  gas,  and,  unless  the  abdominal  wall  is  very 
thick,  the  size  and  position  of  the  organ  may  in  this  way 
be  determined. 

Tests  are  also  made  to  determine  the  condition  of  the 
gastric  secretions,  the  absorptive  activity,  and  the  motor 
activity  of  the  stomach. 

Test-meals. — For  the  first,  an  examination  is  made  of 
the  gastric  contents  during  digestion;  for  this  purpose 
the  patient  is  given  what  is  known  as  a  test-meal.  The 
meal  is  given  on  an  empty  stomach,  usually  after  the 
night's  rest;  the  patient  is  cautioned  to  masticate  thor- 
oughly and  to  eat  slowly.  After  a  given  time  the  contents 
of  the  stomach  are  siphoned  off  by  the  stomach-pump. 
The  test-meals  usually  employed  are  the  breakfasts  of 
Ewald  or  of  Boas,  or  the  test-meal  of  Riegel. 

EWALD'S  BREAKFAST.  BOAS'  BREAKFAST. 

1  roll.  6  ounces  thin  oatmeal  gruel. 

£  pint  of  tea  without  milk  or 
sugar  (or  %  pint  of  water) . 

Remove  at  the  end  of  an  hour. 

RIEGEL'S  TEST-MEAL. 

8  ounces  plain  meat  broth. 

7  ounces  tender  broiled  beef-steak. 

H  ounces  mashed  potato  (or  a  roll). 

Remove  three  hours  after  consumption. 


THE   VOMIT  US  259 

Chemical  tests  are  then  applied  to  the  contents  thus 
removed,  to  determine  the  total  acidity  of  the  gastric 
contents,  the  presence  of  the  digestive  ferments,  and  of 
various  acids  elaborated  during  digestion. 

The  normal  acidity  of  the  gastric  juice  is  due  to  free 
hydrochloric  acid,  a  natural  secretion  of  the  stomach  essen- 
tial to  the  digestion  of  nitrogenous  foods  (Chap.  XXI). 
In  health  the  gastric  juice  contains  about  0.2  per  cent, 
hydrochloric  acid.  The  acidity  of  the  gastric  contents  is 
often  of  diagnostic  value.  In  health  the  acidity  may  be 
persistently  increased  (hyperacidity,  hyperchlorhydria)  by 
the  overuse  of  nitrogenous  or  richly  seasoned  foods,  and 
in  persons  of  highly  nervous  temperament;  hyperacidity 
is  usually  present  in  cases  of  gastric  ulcer  and  in  a  variety 
of  nervous  disorders.  A  decrease  of  acidity  (subacidity) 
is  a  common  accompaniment  of  prolonged  disturbed  gastric 
conditions,  such  as  chronic  gastritis  from  a  variety  of 
causes;  in  cancer  of  the  stomach  there  is  usually  either 
marked  subacidity  or  the  acidity  is  entirely  absent  (an- 
acidity] . 

The  motor  activity  of  the  stomach  is  determined  by 
noting  the  amount  of  food  remaining  in  the  stomach  at  a 
given  interval  after  one  or  other  of  the  test-meals  described 
above.  After  two  hours  there  should  be  no  remains  of 
either  of  the  breakfasts,  and  after  seven  hours  but  little 
food  from  the  Riegel  test-meal.  If  any  quantity  of 
the  food  remains,  the  motor  power  of  the  stomach  is 
reduced.  In  place  of  the  test-meals  one  pint  of  cool 
water  may  be  used.  After  an  hour  and  a  half  practically 
no  water  should  remain  in  the  stomach. 

Loss  of  motor  power  is  usually  associated  with  dilatation 
of  the  stomach,  due  either  to  muscular  weakness  of  the 
walls  of  the  stomach  or  to  an  obstruction  at  the  pyloric 
valve,  such  as  cancer. 

The  absorptive  activity  of  the  stomach  is  usually  tested 
by  administering  to  the  patient  a  capsule  containing  15 
grains  of  potassium  iodid,  and  noting  the  length  of  time 
required  before  iodin  is  found  in  the  saliva.  To  test  the 
saliva  a  filter-paper  is  saturated  with  starch  and  touched 
to  the  saliva.  One  or  two  drops  of  strong  nitric  acid  are 


260      EXAMINATION   OF   VOMITUS,    SPUTUM,    EXCRETA 

added,  when,  if  iodin  is  present,  the  paper  will  turn  a 
bright  blue.  If  the  absorptive  activity  is  normal,  the 
reaction  should  take  place  in  from  ten  to  fifteen  minutes. 
The  test  is  not  considered  very  reliable. 

THE  SPUTUM 

By  sputum  we  mean  the  abnormal  secretions  which 
collect  in  the  lungs  and  air-passages  as  a  result  of  inflam- 
matory conditions,  and  are  expelled  by  coughing.  The 
condition  of  the  sputum  represents  the  condition  of  the  af- 
fected organ,  and  is  consequently  of  diagnostic  importance. 
Sputum  may  be  present  in  any  condition  which  alters  or 
overstimulates  the  secretion  in  the  lungs  or  air-passages, 
or  where,  as  from  the  rupture  of  a  blood-vessel  or  abscess, 
extraneous  fluid  may  be  present. 

Sputum  may  be  thin  and  watery  and  easily  coughed 
up,  or  thick,  tenacious,  and  difficult  to  get  rid  of.  Easy 
expectoration  is  usually  considered  a  favorable  sign  in 
disease.  In  old  age  and  in  conditions  of  extreme  prostra- 
tion sputum  is  expectorated  with  great  difficulty,  so  that 
finally  the  secretions  accumulate  in  the  lungs,  practically 
arresting  their  function. 

Sputum  may  be  scanty  or  profuse.  Commonly  it  is 
scanty  at  the  beginning  of  diseases  of  the  lungs,  and 
more  profuse  as  the  disease  progresses.  The  amount  is 
greatest  on  first  wakening,  the  secretions  having  accum- 
ulated in  the  air-passages  during  sleep. 

Sputum  is  described,  according  to  its  composition,  as 
mucoid,  mucopurulent,  rusty,  prune-juice,  watery,  bloody, 
purulent,  red-currant  jelly,  gangrenous  or  fetid,  and  num- 
mular. 

Mucoid. — The  thin  expectoration  common  in  early 
bronchial  congestive  and  other  catarrhal  conditions  of  the 
respiratory  tract  is  known  as  mucoid.  As  inflammation 
progresses  the  mucoid  expectoration  becomes  mucopurulent. 
The  sputum  is  then  thick,  tenacious,  and  greenish-yellow. 
It  is  inoffensive,  with  a  faint,  sweetish  odor  and  taste,  and 
frequently  very  difficult  to  cough  up.  In  the  later  stages 
of  lobar  pneumonia  the  mucopurulent  sputum  has  a 
characteristic  rusty  color.  This  is  due  to  blood  which  has 


THE   SPUTUM  261 

exuded  from  the  inflamed  lung  tissue  and  become  mixed 
with  the  secretion.  It  is  known  as  rusty  sputum. 

In  grave  cases  of  pneumonia  the  blood  is  exuded  from 
the  inflamed  tissue  in  larger  quantities,  and  mixed  with 
disintegrated  organic  matter.  In  consequence  of  the  low 
vitality  of  the  patient  the  blood  is  retained  in  the  air- 
cells  and  passages  for  a  greater  length  of  time,  and  becomes 
altered,  giving  to  the  sputum  a  dark  brownish  color  con- 
sidered to  resemble  prune  juice.  This  is  known  as  prune- 
juice  sputum,  and  is  considered  an  unfavorable  symptom. 
It  is  common  in  the  senile  forms  of  pneumonia. 

The  above  forms  of  sputum  are  common,  and  will  be 
met  with  at  all  times  in  nursing  diseases  of  the  respiratory 
organs.  The  following  are  more  rarely  met  with: 

Watery  Sputum. — The  expectoration  of  quantities  of 
frothy  watery  fluid  is  a  symptom  of  edema  of  the  lungs,  in 
which  condition  the  air-cells  become  filled  with  an  effusion 
of  serous  fluid. 

Bloody  Sputum. — The  expectoration  of  fresh  blood  from 
the  lungs  (hemoptysis)  is  always  a  grave  symptom.  It 
is  bright  red,  mixed  with  air-bubbles,  which  give  it  a  frothy 
appearance  (except  when  in  very  large  quantities),  and  is 
coughed  up;  these  points  should  be  remembered  in  dis- 
tinguishing between  hemorrhage  from  the  lungs  and  from 
the  stomach  (Chap.  XVII).  The  quantity  of  blood  ex- 
pectorated at  a  time  is  not  usually  considerable  unless 
in  case  of  the  rupture  of  a  large  vessel  from  injury  or 
disease.  The  most  common  cause  of  hemorrhage  from 
the  lungs  is  pulmonary  tuberculosis. 

Red-currant  Jelly  Sputum. — This  is  considered  diag- 
nostic of  cancer  of  the  lung.  The  disintegrated  tissue 
mixed  with  the  natural  secretion  of  the  lungs  is  considered 
to  have  the  appearance  of  red-currant  jelly. 

Purulent  sputum,  that  is  to  say,  sputum  composed  almost 
entirely  of  pus,  denotes  that  an  abscess  has  ruptured  in 
the  air-vesicles.  The  abscess  may  be  in  the  lung  tissue 
itself,  as  in  the  suppurative  stages  of  phthisis,  or  from  a 
neighboring  structure,  most  commonly  from  a  pleural 
abscess.  Frequently  almost  the  entire  contents  of  the 
abscess  are  coughed  up  at  one  time.  The  sputum  pre- 


262      EXAMINATION   OF   VOMITUS,   SPUTUM,    EXCRETA 

sents  the  characteristic  appearance  of  pus.  It  is  offensive 
and  frequently  streaked  with  bright  blood. 

Gangrenous  Sputum. — Gangrenous  sputum  is  recognized 
by  its  overpowering  fetid  odor.  It  indicates  that  some 
portion  of  the  lung  tissue  has  become  gangrenous.  This 
occurs  most  commonly  in  advanced  phthisis  or  from  ul- 
ceration  of  the  walls  of  the  bronchi  in  chronic  dilatation 
of  the  bronchi.  The  condition  may  also  result  from  acci- 
dental injury,  such  as  a  gun-shot  wound. 

Sputum  in  Tuberculosis. — The  sputum  in  pulmonary 
tuberculosis  has  a  characteristic  round,  flat  appearance, 
to  which  the  name  nummular  has  been  given,  from  its 
supposed  resemblance  to  a  small  coin.  It  is  expectorated 
in  small,  separate,  semisolid,  round,  flat  masses,  consider- 
ably denser  than  the  usual  forms  of  sputum.  Placed  in 
water,  these  small  masses  sink  to  the  bottom,  whereas 
ordinary  sputum,  freely  incorporated  with  air-bubbles, 
floats  on  the  top. 

False  Coloring  of  Sputum. — The  sputum  of  miners  and 
chimney-sweeps  will  generally  be  of  an  abnormally  dark 
color  or  speckled  with  small  black  particles.  This  is 
due  to  atoms  of  coal-dust,  with  which  the  lung  tissue 
has,  in  course  of  time,  become  impregnated.  The  sputum 
of  inveterate  tobacco  smokers  may  also  have  a  character- 
istic discoloration. 

Sputum  as  a  Source  of  Infection. — In  all  infectious  dis- 
eases of  the  lungs  or  air-passages  the  bacteria  of  the  disease 
will  probably  be  found  in  the  sputum.  This  is  in  a  special 
degree  the  case  in  pulmonary  tuberculosis,  where  the  pres- 
ence of  the  organisms  in  the  sputum  is  considered  conclu- 
sive proof  of  the  disease.  The  sputum  in  such  infections  as 
diphtheria,  scarlet  fever,  etc.,  contains  discharges  from  the 
throat,  in  which  the  bacteria  of  the  disease  are  present  in 
large  quantities.  In  the  sputum  of  diphtheria  shreds  of 
false  membrane  are  frequently  present.  All  such  sputum 
must  be  regarded  as  infectious,  and  means  taken  that  it 
should  not  be  allowed  to  become  a  source  of  danger  or 
channel  of  infection  to  others. 

Sputum-cups. — Sputum  not  required  for  examination 
should  be  received  in  vessels  containing  a  disinfectant, 


THE   SPUTUM  263 

and  closely  covered  when  not  in  use.  A  great  source  of 
infection  from  sputum-cups  is  in  small  deposits  allowed 
to  accumulate  on  the  brims;  these  are  left  exposed  to  flies, 
whom  we  now  regard  as  important  transmitters  of  disease, 
or,  allowed  to  dry,  become  detached,  and  float  as  imper- 
ceptible particles  in  the  air  (p.  414).  Sputum-cups  should 
be  cleaned  at  least  twice  a  day,  scrubbed  with  hot  suds,  and 
boiled  for  ten  minutes  at  least  once  in  the  twenty-four 
hours.  In  cleaning  the  cups  care  must  be  taken  not  to 
contaminate  the  fingers,  and  the  habit  should  be  insisted 
upon  of  thoroughly  cleansing  the  hands  immediately  after 
the  operation. 

Where  sputum-cups  are  not  used,  the  sputum  should 
l)e  received  in  small  squares  of  soft  paper  or  rag  and 
burned.  (See  also  p.  437.) 

Examination  of  Sputum. — When  sputum  is  required 
for  examination,  it  should  be  coughed  directly  into  a  wide- 
mouthed  glass  bottle,  previously  sterilized,  and  corked  with 
sterile  absorbent  cotton.  The  outside  of  the  bottles  should 
be  carefully  wiped  with  a  cloth  saturated  with  a  solution 
of  bichlorid  of  mercury,  1  :  1000,  or  other  strong  disin- 
fectant. A  common  cause  of  infection  in  laboratories  is 
traced  to  the  handling  of  such  bottles,  on  the  outside  of 
which  small  quantities  of  sputum  have  been  deposited  and 
left  to  dry. 

The  specimen  of  sputum  from  a  child  is  often  difficult 
to  obtain,  children  having  a  tendency  to  swallow  their 
sputum.  A  practical  method  is  as  follows:  Roll  a  piece 
of  sterile  gauze  round  your  finger;  during  the  attack  of 
coughing  pass  the  finger  quickly  to  the  back  of  the  throat, 
fold  the  gauze  round  the  sputum  which  adheres,  and  place 
directly  in  a  sterile  bottle. 

The  microscopic  examination  of  sputum  is  for  the  pur- 
pose of  observing  certain  crystals  which  have  a  diagnostic 
value,  and  for  the  detection  of  any  bacteria  present,  the 
most  important  of  which  is  the  rod-shaped  bacillus  of 
tuberculosis.  In  many  hospitals  nurses  are  taUght  a 
simple  method  of  preparing  such  specimens  and  to  examine 
them  under  the  microscope  (p.  400). 


264      EXAMINATION   OF   VOMITUS,   SPUTUM,   EXCRETA 

THE  EXCRETA 
THE   FECES 

The  condition  of  the  feces,  as  passed  in  the  evacuations 
of  the  bowel,  is  important  both  in  health  and  in  disease, 
and  requires  intelligent  observation. 

Normal  Stool. — The  stools  are  formed  of  the  debris  of 
food-stuffs,  mixed  with  the  digestive  juices  and  excretions 
of  the  alimentary  canal,  including  the  bile,  which  gives 
the  feces  a  golden-brown  color.  In  a  healthy  condition 
the  stool  should  be  formed  or  semiformed,  from  light  to 
dark  brown  in  color,  of  one  consistence  throughout,  and 
with  a  characteristic  fecal  odor. 

Stool  in  Infancy. — The  first  evacuations  of  the  new-born 
infant  are  liquid,  sticky,  dark  brown  in  color,  and  odorless. 
They  consist  of  meconium,  the  contents  of  the  bowel  at 
birth,  and  contain  no  food-substances. 

The  meconium  is  replaced  by  the  golden-yellow  stools 
of  the  suckling,  which  have  about  the  color  and  consistence 
of  freshly  made  mustard  paste,  and  should  be  smooth, 
almost  odorless,  and  free  from  undigested  curds  of  milk 
or  mucus. 

Stool  of  Milk  Diet. — In  young  children  and  in  patients 
fed  entirely  on  a  milk  diet  the  stools  are  yellow  in  color  and 
have  less  odor  than  when  a  richer  diet  is  taken,  less  com- 
pletely digested,  and  more  likely  to  produce  fermentation. 

Consistence  of  Stools  in  Constipation. — When  the  feces 
remain  too  long  in  the  bowel,  they  become  dry,  hard,  and 
darker  in  color,  and  are  passed  with  pain  and  difficulty; 
frequently  they  may  be  streaked  with  blood  from  slight 
bleeding  at  the  anus. 

In  Diarrhea. — In  diarrhea  the  consistence  of  the  stools 
is  changed  and  their  frequency  increased;  they  become 
loose,  liquid,  or  watery,  and  should  be  examined  for  un- 
digested food,  mucus,  and  blood. 

Undigested  Stools. — In  infants,  young  children,  and 
those  fed  on  milk  it  is  common  to  find  curds  of  milk  in 
the  stools.  In  a  breast-fed  baby  these  have  the  appearance 
of  small  light  spots  of  more  solid  consistence  than  the 
stool;  in  a  bottle-fed  baby  the  curd  is  larger  and  more 


THE   FECES  265 

easily  recognized.  Where  the  stool  is  otherwise  healthy, 
curds  passed  in  the  stools  usually  indicate  either  that  too 
much  milk  is  being  taken  at  one  time,  that  the  proportion 
of  protein  is  too  large,  or  that  there  is  a  deficiency  of  the 
gastric  juice,  conditions  easily  modified.  Where,  besides 
containing  curds,  the  stool  is  greenish,  slimy,  and  offensive, 
the  digestion  is  seriously  disturbed.  Shreds  of  undigested 
food  are  also  not  serious  if  the  stool  is  otherwise  healthy, 
but  should  be  noted  and  the  diet  corrected  by  their  indi- 
cation. Improper  mastication  and  bolting  of  food  are 
common  causes  of  undigested  stools. 

Watery  Stools. — Stools  of  very  thin  consistence,  known 
as  watery  stools,  are  noticed  in  all  forms  of  cholera,  as 
cholera  morbus,  cholera  infantum,  etc.,  and  are  a  severe 
drain  on  the  system.  In  these  conditions  the  movements 
are  accompanied  by  acute  cramping  pains.  Watery 
stools  may  also  be  the  result  of  the  action  of  saline  pur- 
gatives, or  of  such  drastic  purgatives  as  croton  oil  (1  to 
2  minims)  or  elaterium  (TV  to  |  grain),  and  are  a  charac- 
teristic symptom  in  corrosive  or  irritant  poisoning. 

Mucus. — The  presence  of  mucus  in  the  stool  gives  it 
a  slimy  appearance,  and  indicates  intestinal  irritation; 
it  is  a  symptom  in  enteritis,  colitis,  and  dysentery,  and 
may  follow  overpurging  from  any  cause.  Where  the 
small  intestine  is  the  seat  of  irritation,  the  mucus  is  mixed 
with  the  stool  substance;  in  inflammation  of  the  colon  it 
lies  on  the  surface  of  the  stool.  After  free  purging  the 
evacuation  may  consist  entirely  of  mucus.  In  an  inflam- 
matory condition  known  as  mucous  colitis  mucus  is  passed 
in  long  strands  of  pseudomembrane,  forming  frequently 
regular  casts  of  the  bowel. 

Blood. — Blood  in  the  stools  may  result  from  overpurg- 
ing, from  acute  catarrhal  or  inflammatory  conditions  of 
the  intestines,  or  from  lesions  giving  rise  to  hemorrhages 
in  some  part  of  the  alimentary  canal.  The  blood  may  be 
either  fresh  or  altered,  intimately  mixed  with  the  stool, 
or  lying  on  the  surface;  it  may  be  passed  in  any  quantity, 
from  a  few  streaks  to  a  copious  outpouring  immediately 
fatal  to  life. 

Mixed  with  mucus  and  passed  in  small  quantities  with 


266      EXAMINATION  OF  VOMITUS,   SPUTUM,   EXCRETA 

the  stool,  it  is  a  common  accompaniment  of  intestinal 
inflammation;  passed  after  the  stool  and  free  from  mucus, 
it  generally  signifies  bleeding  from  the  anus,  of  which  the 
most  common  cause  is  hemorrhoids.  Bloody  stools  occur 
in  cancer  of  the  rectum  or  other  portions  of  the  alimentary 
canal,  in  scurvy,  and  in  purpura,  in  which  latter  condition 
the  quantity  of  blood  passed  at  a  time  is  frequently  great. 

Hemorrhage  From  the  Bowels. — Hemorrhage  or  pro- 
fuse bleeding  from  the  bowels  is  commonly  the  result  of  an 
ulcerated  condition  of  the  stomach  or  intestines,  and  may 
be  looked  for  in  typhoid  fever  and  in  gastric  and  duodenal 
ulcers.  If  a  fresh  hemorrhage,  occurring  low  down  in 
the  intestine,  the  blood  is  bright  red  and  clots  quickly, 
often  before  being  passed;  if  it  has  remained  some  time  in 
the  intestine,  it  has  become  altered  by  the  digestive  juices 
and  intimately  mixed  with  the  stools,  to  which  it  imparts  a 
characteristic  black,  tarry  appearance. 

Hemorrhage  from  the  bowels  is  always  a  condition  of 
the  gravest  importance  (p.  614).  After  operations  on 
any  part  of  the  alimentary  canal  the  appearance  of  blood 
in  the  stool  should  be  watched  for.  In  examining  stools, 
especially  for  blood,  the  possibility  of  the  presence  of 
vaginal  discharges  should  be  borne  in  mind. 

Pus. — Pus  in  the  stools  is  not  easy  to  detect  in  small 
quantities,  and  microscopic  examination  is  resorted  to; 
in  a  larger  amount  it  may  be  mistaken  for  a  thick,  liquid 
stool,  especially  if  colored  by  the  feces  and  having  a  fecal 
odor.  In  small  quantities  and  mixed  with  the  stool  pus 
is  a  symptom  of  severe  intestinal  inflammation;  passed  in 
a  larger  quantity,  with  or  without  a  stool,  usually  it  is  the 
result  of  the  rupture  of  an  abscess  into  the  intestinal 
tract. 

Fat. — Fat  is  sometimes  detected  in  the  stools  in  chronic 
diseases  of  the  pancreas  or  where  fat  is  taken  too  freely  in 
the  diet.  The  stools  of  patients  fed  chiefly  on  cream,  as 
in  some  infant  feeding  and  in  the  high  caloric  liquid  diet 
ordered  by  some  physicians  in  typhoid  cases,  should  be 
examined  for  fat-particles,  loosely  and  wrongly  called 
fat-curds. 

Odor  of  Stools. — Stools  are  made  offensive  by  the  action 


THE   FECES  267 

of  bacteria,  by  decomposed  food-particles,  or  by  being 
mixed  with  offensive  discharges,  as  from  cancer  or  an 
abscess  opening  into  some  part  of  the  intestines.  Offensive 
stools  are  characteristic  of  enteritis,  of  typhoid  fever,  and 
of  the  diarrhea  of  tuberculosis  and  other  septic  conditions. 

Color  of  Stools. — The  green  color  so  frequently  seen  in 
unhealthy  stools  is  usually  attributed  to  the  action  of  in- 
testinal bacteria,  or  may  be  caused  by  an  excessive  amount 
of  bile  (Stevens).  It  is  common  in  many  forms  of  intestinal 
irritation,  especially  in  the  enteritis  of  children. 

Persistent  greenish-yellow,  liquid  stools,  of  the  consistence 
and  appearance  of  pea-soup,  with  an  offensive  odor,  are  a 
characteristic  symptom  of  typhoid. 

Stools  may  be  turned  black  by  the  presence  of  altered 
blood,  and  are  then  known  as  tarry  stools,  or  by  certain 
drugs,  iron,  bismuth,  and  charcoal.  Food  which  contains 
iron,  such  as  spinach,  will  also  cause  black  stools.  Black 
stools  are  described  as  melanotic. 

Methylene-blue  will  impart  a  blue  color  to  the  stools, 
and  logwood  will  color  them  bright  red.  The  latter  is 
important  to  bear  in  mind,  as  logwood  is  an  astringent  not 
infrequently  used  in  the  diarrheas  of  childhood,  and  the 
red  color,  resembling  blood,  gives  the  stool  an  alarming 
appearance. 

The  possibility  of  coloring  the  stools  by  drugs  taken  by 
the  mouth  is  made  use  of  in  determining  the  time,  in 
different  cases,  required  for  food-stuffs  to  pass  through 
the  intestines;  in  other  words,  the  motor  activity  of  this 
part  of  the  digestive  tract.  A  coloring  substance,  such  as 
one  of  the  anilin  dyes,  which  has  no  action  on  the  intestines, 
their  secretions,  or  their  contents,  is  given,  and  the  length 
of  time  between  its  administration  and  the  staining  of  the 
stools  the  characteristic  color  is  noted. 

Absence  of  Color. — Absence  of  color  denotes  absence  or 
diminution  in  the  quantity  of  bile,  and  the  result  is  the 
clay-like  stool  found  in  jaundice,  associated  with  inflamma- 
tion or  obstruction  of  the  bile-duct.  A  chalky  appearance 
somewhat  resembling  the  clay-colored  stool  may  be  given 
to  the  light  stools  of  young  children  by  the  administration 
of  chalk. 


268   EXAMINATION  OF  VOMITUS,  SPUTUM,  EXCRETA 

Poisons. — Very  many  of  the  poisons  are  eliminated  by 
the  stools,  and  their  diagnostic  value  in  such  cases  should 
be  remembered.  In  poisoning  from  phosphorus  the  stools 
have  a  phosphorescent  or  luminous  appearance  when 
placed  in  the  dark.  Poisoning  by  the  irritants  or  corrosives 
will  be  accompanied  by  mucous,  bloody,  or  watery  stools, 
according  to  the  severity  of  the  injury  to  the  alimentary 
tract. 

Foreign  Bodies. — Foreign  bodies,  such  as  coins,  buttons, 
small  playthings,  and  the  stones  of  fruits,  are  not  infre- 
quently found  in  the  bowel  movements  of  children,  and  are 
easily  recognized.  Less  easy  of  detection  are  small  gall- 
stones, which  occasionally  find  their  way  into  the  intestines 
through  the  bile-ducts  and  are  passed  in  the  stools.  Where 
their  presence  is  looked  for,  the  stool  maybe  rubbed  through 
a  seive,  or  it  may  be  turned  on  to  a  double  piece  of  cheese- 
cloth, about  a  yard  long,  the  ends  of  which  are  then  forcibly 
twisted  in  opposite  directions,  thus  wringing  the  stool 
through  the  cheese-cloth.  This  should  be  done  under  a 
running  tap  of  cold  water.  When  the  stool  has  been 
squeezed  and  washed  away,  the  cheese-cloth  is  opened  and 
the  gall-stones  may  be  found.  They  are  irregular  bodies, 
of  extremely  light  weight,  and  may  be  brown  or  pearly 
white;  they  vary  greatly  in  size,  but  those  passed  in  the 
stools  are  generally  very  small,  and  might  easily  be  mis- 
taken for  fruit-seeds. 

Parasites. — Round  worms  and  segments  of  the  various 
tape-worms  which  may  infest  the  intestine  are  frequently 
met  with  in  the  stools.  The  common  earth-worm  is 
easily  recognized.  Seat-worms,  often  passed  in  great  num- 
bers, appear  like  little  threads,  and  usually  are  moving 
actively;  the  largest  is  about  half  an  inch  long.  Segments 
of  the  tape-worm  appear  as  nearly  square  white  bodies, 
attached  together  in  chain-like  formation.  Where  the 
whole  worm  is  recovered,  it  may  be  several  yards  in  length. 
Where  treatment  is  given  to  expel  a  tape-worm,  it  is  desir- 
able to  preserve  it  intact,  and  in  particular  to  ascertain 
if  the  small  head,  with  its  hooklets,  has  come  away.  The 
head  is  extremely  minute,  the  size  of  a  pin's  head,  with  a 
neck  like  a  delicate  thread,  and  is,  therefore,  easy  to  lose. 


THE    URINE  269 

It  is  the  most  important  part  of  the  worm,  as  if  left  in  the 
intestine  the  body  will  grow  again. 

Bacteria. — In  many  infectious  diseases  the  stools  con- 
tain the  bacteria  of  the  disease  in  great  numbers.  This 
is  especially  the  case  in  typhoid  fever,  cholera,  and  all  the 
"  water-borne  "  (p.  414)  infections.  Pupils  should  be 
carefully  taught  from  the  beginning  practical  precautions 
in  dealing  with  these  stools  (p.  433).  The  smallest  stain 
from  a  stool  on  linen  or  vessel  should  be  regarded  as  an 
active  colony  of  bacteria  and  a  prolific  channel  of  infection. 

In  typhoid  fever  it  should  be  borne  in  mind  that  bacteria 
may  persist  in  the  stools  long  after  recovery,  making  the 
patient  a  menace  to  the  health  of  those  with  whom  he 
lives. 

Preparation  of  Stool  for  Examination. — Where  a  stool 
is  to  be  preserved  for  examination,  it  is  obviously  necessary 
that  the  vessel  should  be  absolutely  clean  and  free  from 
such  foreign  bodies  as  fluff,  dust,  and  hairs.  A  specimen 
glass  or  a  glass  preserving-jar  is  used  to  put  up  the  speci- 
men, and  should  be  sterilized  either  by  boiling  or  in  the 
autoclave  before  use.  No  disinfectant  should  be  mixed 
with  a  stool  that  is  required  for  examination.  Usually 
only  a  small  portion  of  the  stool  is  necessary  for  examina- 
tion, but  if  there  is  any  abnormal  appearance,  such  as  a 
quantity  of  pus,  etc.,  the  whole  should  be  preserved  as 
far  as  possible  undisturbed.  Specimens  should  be  closely 
covered  and  accurately  labeled.  Usually  the  hour  of 
passing  the  stool  is  noted,  as  it  is  often  important  to  make 
the  examination  as  early  as  possible. 

In  disorders  of  the  digestive  organs,  in  cases  of  mal- 
nutrition, and  in  other  conditions  the  stools  are  often 
required  to  be  weighed.  This  is  usually  done  in  the 
vessel  or  napkin  in  which  the  stool  is  passed,  and  the  weight 
of  the  vessel  or  napkin  deducted  from  the  amount. 

THE   URINE 

Urine  is  a  clear,  amber-colored  fluid  secreted  by  the 
kidneys,  stored  in  the  bladder,  and  voided  under  normal 
conditions,  voluntarily  and  without  pain. 


270      EXAMINATION   OF   VOMITUS,   SPUTUM,   EXCRETA 

Composition. — Urine  is  composed  of  about  960  parts  of 
water  to  40  of  solid  matter.  This  proportion  is  modified 
in  health  by  transitory  conditions,  as,  for  example,  the 
ingestion  of  foods  or  fluids,  after  severe  sweating,  as  the 
result  of  exercise,  etc.;  it  is  also  altered  in  those  diseases 
associated  with  disturbances  of  nutrition,  such  as  fevers. 

Solids. — The  solid  portion  of  urine  is  composed  of 
urea,  uric  acid,  inorganic  salts,  a  small  amount  of  organic 
matter,  aromatic  substances,  and  pigment. 

Urea. — Urea  is  the  chief  solid  constituent  of  the  urine, 
and  the  elimination  of  urea  we  may  take  as  the  most 
important  function  of  the  kidneys.  Urea  is  produced 
in  the  body  as  the  result  of  the  combustion  or  oxidation 
of  protein  or  nitrogenous  food  (Chap.  XXI).  If  allowed 
to  accumulate  in  the  blood,  symptoms  of  acute  poison- 
ing quickly  manifest  themselves,  followed  by  death  if 
the  condition  is  not  relieved.  By  far  the  larger  portion  of 
the  elimination  of  urea  is  performed  by  the  kidneys,  the 
small  amount  lost  in  normal  conditions  through  the  activ- 
ity of  the  sweat-glands  being  insufficient  to  avert  poisoning. 
In  a  normal  condition  about  one  ounce  of  urea  is  excreted 
in  the  urine  in  twenty-four  hours.  The  average  propor- 
tion of  urea  in  a  twenty-four-hour  specimen  of  healthy 
urine  is  about  2  per  cent.,  or  one-half  the  entire  solid  con- 
stituents of  urine.  The  proportion  of  urea  in  the  urine  is 
temporarily  increased  by  the  following  conditions:  (1) 
A  meal  of  protein  food;  (2)  after  exercise;  (3)  in  the  early 
stages  of  acute  fevers.  It  ;s  permanently  present  in  ex- 
cess in  the  urine  of  diabetic  patients.  The  proportion  is 
decreased  after:  (1)  The  ingestion  of  large  quantities  of 
water;  (2)  in  conditions  of  lowered  vitality;  and  (3)  in 
some  diseases  of  the  liver  and  kidney. 

Uric  Acid. — Uric  acid  is  also  considered  to  be  a  result 
of  the  nitrogenous  waste  of  the  body.  It  is  found  in  the 
urine  usually  in  the  form  of  uric  acid  salts  or  urates. 
Urates  are  formed  by  the  combination  of  uric  acid  with  one 
or  other  of  the  solid  constituents  of  urine,  lime,  soda,  mag- 
nesia, etc.  The  presence  of  urates  in  excess  gives  to  the 
urine  a  turbid  appearance  on  cooling,  and  an  increase  of 
acidity.  A  persistent  excess  of  uric  acid  is  apt  to  lead  to 


THE    URINE  271 

the  formation  of  deposits  which  develop  into  urinary 
calculi,  or  "  stones." 

The  proportion  of  uric  acid  is  temporarily  increased  by 
nitrogenous  food  and  by  conditions  that  tend  to  concen- 
trate urine,  such  as  severe  sweating,  etc.;  it  is  temporarily 
diminished  after  drinking  quantities  of  water.  Many 
forms  of  disease  are  accompanied  by  increase  in  the  quan- 
tity of  urates,  especially  those  in  which  the  processes  of 
nutrition  are  impaired,  such  as  fevers.  Another  product 
of  nitrogenous  waste,  known  as  creatinin,  is  also  normally 
present  in  urine.  It  is  of  minor  importance. 

Salts. — In  chemistry  the  product  of  the  union  of  an  acid 
with  a  base  or  element  is  called  a  salt.  The  bases  of  a 
variety  of  salts  are  found  in  normal  urine.  The  principal 
are  urea,  magnesia,  lithia,  potash,  and  soda,  phosphoric 
acid,  sulphuric  acid,  and  chlorin,  the  combination  of  which 
form  such  salts  as  phosphate  of  magnesia,  sodium  chlorid, 
etc. 

Pigments. — Pigments  give  the  urine  its  characteristic 
amber  color.  The  most  important  is  urorobin.  They  are 
present  in  a  larger  proportion  in  concentrated  urine, 
which  has,  consequently,  a  higher  color  than  that  passed 
in  larger  quantities.  When  passed  in  abnormally  large 
quantities,  urine  is  nearly  colorless. 

Aromatic  Substances. — A  few  aromatic  substances  are 
present  in  urine,  of  which  the  most  important  is  hippuric 
acid. 

Organic  Matter. — The  principal  organic  substances 
found  in  urine  are  mucus,  epithelium,  and  fat,  in  very 
minute  quantities. 

Specific  Gravity. — The  specific  gravity  or  density  of 
either  a  fluid  or  a  solid  is  ascertained  by  referring  to 
water  as  the  unit  of  comparison.  A  body  twice  the 
weight  of  water,  bulk  for  bulk,  is  said  to  have  a  specific 
gravity  of  two;  ten  times,  the  weight  of  ten,  and  so  forth. 
The  solid  substances  in  urine  give  it  greater  weight  or 
"  higher  specific  gravity  "  than  water.  Taking  the  specific 
gravity  of  water  at  1000,  normal  urine  has  a  specific 
gravity  of  from  1015  to  1025 — i.  e.,  1.5  to  2.5  more  than 
the  weight  of  water.  The  specific  gravity  is  higher  in 


272      EXAMINATION  OF   VOMITUS,    SPUTUM,    EXCRETA 

concentrated  urines  rich  in  urea;  and  abnormally  high, 
1035  and  over,  in  the  disease  known  as  diabetes  mellitus, 
where  the  urine  although  passed  in  enormous  quantities, 
contains  sugar,  and  is  usually  rich  in  urea.  It  is  lower  in 
pale,  copious  urines  deficient  in  urea,  and  usually  in  those 
conditions  where  the  urine  contains  albumin. 

Reaction. — Normal  urine  has  a  slightly  acid  reaction, 
which  varies  somewhat  at  the  different  times  of  the  day. 
After  a  meal,  especially  of  vegetables,  it  is  neutral  or 
may  be  alkaline.  The  acidity  is  greater  in  conditions 
where  the  uric  acid  is  increased,  especially  in  diseases 
which  are  associated  with  excess  of  uric  acid,  such  as 
gout  and  rheumatism. 

Urine  becomes  alkaline  upon  decomposition,  either 
within  the  bladder,  as  in  the  urine  of  cystitis  (inflammation 
of  the  bladder),  or  after  it  has  been  passed.  The  latter 
is  the  result  of  bacterial  activity,  and  may  be  averted 
for  a  length  of  time  by  keeping  the  specimens  in  a  clean, 
sterile  vessel  closely  covered  from  the  air.  Urine  may 
also  be  rendered  alkaline  by  the  inhibition  of  alkaline 
waters,  such  as  lithia  water,  etc.  Pus  also,  if  present  in 
the  urine,  gives  it  an  alkaline  reaction. 

Abnormal  Substances  Found  in  Urine. — The  constitu- 
ency of  urine  is  affected  in  many  diseases  and  disordered 
conditions  of  health.  In  some  cases  one  or  other  of  the 
normal  constituents  may  be  either  present  in  excess  or 
reduced  in  proportion;  in  other  cases  extraneous  substances 
may  be  found.  The  principal  extraneous  substances 
that  may  be  looked  for  are  albumin,  blood,  pus,  bile,  and 
sugar,  and  more  rarely  chyle.  In  many  of  the  infectious 
diseases  the  bacteria  producing  the  disease  are  observed 
in  the  urine.  In  cases  of  poisoning  by  drugs,  traces  of 
the  poison  may  often  be  found  in  the  urine;  the  urine, 
therefore,  of  suspected  cases  should  invariably  be  saved 
for  examination. 

Color. — The  color  of  urine  is  changed  by  deposits  and 
by  several  drugs.  Thus  an  excess  of  urates  will  give  urine 
an  orange-red  color. 

Blood  imparts  a  smoky  appearance  or  a  blood-red  color. 

Bile  gives  the  color  of  porter. 


THE    URINE  273 

A  quantity  of  mucus  or  the  presence  of  pus  or  chyle 
gives  urine  a  milky  appearance. 

A  pink  sediment  frequently  seen  in  concentrated  urine 
is  due  to  the  action  of  urates  on  the  pigments;  it  disap- 
pears when  the  urates  are  dissolved. 

Drugs  which  may  give  a  characteristic  color  to  urine 
are  as  follows: 

lodofprm,  carbolic  acid,  and  its 

derivatives Dark  olive-green. 

Rhubarb  and  senna Bright  orange  color. 

Logwood Bright  red    (may  be    mistaken   for 

blood) . 

Santonin Saffron  yellow. 

Methylene-blue A   blue-green  color   (often   used  for 

diagnostic  purposes) . 

Clearness. — The  above  conditions  also  affect  the  clear- 
ness of  urine.  Thus  urine  containing  blood,  bile,  mucus, 
or  pus  is  opaque  in  proportion  to  the  quantity  of  the 
deposit.  Urine  containing  an  excess  of  urates  is  thick  and 
turbid  after  it  cools,  though  on  passing  it  is  quite  clear. 
A  light,  flocculent  cloud  floating  in  clear  urine  is  usually 
due  to  a  small  quantity  of  mucus  and  has  no  significance. 

Odor. — The  odor  of  urine  is  like  nothing  else,  and  is 
described  as  urinous.  On  decomposition  it  becomes  am- 
moniacal.  Freshly  voided  urine  with  an  ammoniacal 
odor  points  to  cystitis.  The  odor  is  affected  by  drugs  to  a 
slight  extent;  thus  turpentine  is  said  to  give  urine  an  odor 
of  violets;  sandal  wood,  tolu,  cubebs,  and  copaiba  each 
impart  a  characteristic  odor.  Asparagus,  even  taken  in 
small  quantities,  gives  urine  a  disagreeable  odor. 

Quantity. — The  normal  quantity  of  urine  voided  in 
twenty-four  hours  is  from  2  to  3  pints.  The  quantity 
may  be  temporarily  increased  by  excitement,  exertion, 
the  application  of  cold  to  the  skin,  or  by  drinking  a  quantity 
of  fluid,  and  by  the  action  of  certain  drugs  known  as 
diuretics;  it  is  usually  increased  in  hysteria,  during  a 
crisis,  and  in  most  cases  of  chronic  Bright's  disease;  in 
diabetes  the  quantity  is  enormously  increased  and  may 
average  several  quarts  a  day.  A  temporary  marked 
increase  in  the  quantity  of  urine,  as,  for  example,  during 
a  crisis,  is  called  a  diuresis;  a  more  permanent  condition 

18 


274      EXAMINATION   OF    VOMITUS,    SPUTUM,    EXCRETA 

of  increased  quantity  is  known  as  polyuria.  In  some  acute 
diseases  a  mild  condition  of  polyuria  is  considered  a  favor- 
able symptom.  This  is  especially  the  case  in  typhoid 
fever. 

A  decrease  in  the  quantity  of  urine  is  noticed  in  all 
fevers,  in  acute  diseases  of  the  kidneys,  and  in  conditions 
associated  with  dropsy,  in  uremia  and  after  severe  hemor- 
rhages, vomiting,  or  diarrhea;  the  quantity  may  be  de- 
creased by  a  dry  diet  and  by  the  action  of  drugs  that 
diminish  secretions,  such  as  opium  and  ergot.  When  the 
quantity  passed  is  very  small,  the  condition  is  known  as 
oliguria;  when  no  urine  is  secreted,  it  is  termed  anuria, 
Anuria,  if  persistent,  is  quickly  fatal  to  life,  owing  to  the 
accumulation  of  urea  in  the  system. 

EXAMINATION  or  THE  URINE 

The  condition  of  urine  is  such  an  important  aid  to  diag- 
nosis that  its  examination  is  in  all  diseases  a  matter  of 
routine  work.  A  specimen  for  examination  should  be 
taken  either  from  the  collected  quantity  passed  in  twenty- 
four  hours  or  from  the  urine  voided  first  in  the  morning, 
before  food  or  drink  is  taken.  Urine  passed  after  the 
ingestion  of  food  is  rich  in  solids,  especially  in  urea,  while 
the  urine  after  drinking  contains  a  larger  proportion  of 
water;  the  urine  first  voided  after  the  night's  fast  is,  there- 
fore, the  purest  specimen.  Where  urine  is  collected  for 
twenty-four  hours,  the  reckoning  should  begin,  to  insure 
accuracy,  immediately  after  the  first  voiding  after  the 
night's  sleep  one  morning  (the  specimen  not  to  be  included), 
and  end  with  and  include  the  first  voiding  on  the  following 
morning,  as  nearly  as  possible  at  the  same  hour.  When 
vaginal  discharges  are  present,  the  specimen  is  procured 
by  catheter. 

The  vessel  in  which  the  specimen  is  put  up  must  be 
sterilized  by  boiling  and  perfectly  clean,  free  from  dust, 
fluff,  or  hair,  etc.,  which  interfere  with  the  examination 
of  the  specimen  and  may  set  up  decomposition  in  the 
urine. 

Each  specimen  should  be  accurately  labeled  with  the 
name,  date,  hour  of  passing,  quantity  from  which  the 


EXAMINATION   OF  THE    URINE 


275 


FOR  URINE 

ANALYSIS 


specimen  is  taken,  and  a  note  as  to  whether  it  is  the  speci- 
men of  a  single  voiding  or  of  a  twenty-four-hour  collection 
of  urine.  Urine  is  examined  both  by  microscope  and  by 
chemic  tests. 

Microscopic  Examination. — The  microscope  is  used  to 
examine  organic  matter,  the  crystals  of  various  salts,  and 
to  detect  the  presence  of  bacteria. 

A  specimen  for  microscopic  examination  is  placed  in  a 
conic-shaped  glass,  and  any  deposit  present  allowed  to 
settle  to  the  bottom.  The  liquid  part  may  be  poured 
off,  and  the  deposit  ex- 
amined separately.  The 
process  in  laboratory  work 
is  hastened  by  the  use  of  an 
apparatus  called  a  centri- 
fuge (Fig.  61),  on  the  tubes 
being  rapidly  rotated  the 
solid  and  fluid  particles  are 
separated;  it  acts  on  much 
the  same  principle  as  a 
dairy  cream  separator. 

The  principal  abnormal 
organic  constituents  of  urine 
are  blood,  pus,  and  what 
are  known  as  casts. 

Casts. — Casts  are  the  results  of  an  abnormal  exudate, 
generally  of  serum,  from  the  blood  into  the  uriniferous 
tubes  of  the  kidney;  the  exudate  becomes  coagulated,  and 
is  passed  out  in  the  urine  as  microscopic  molds  or  casts  of 
the  tubes,  of  varying  size.  Their  presence  is  a  sign  of  an 
inflamed  or  diseased  condition  of  the  kidney. 

Simple  casts,  formed  of  a  clear,  pellucid  exudate,  with- 
out debris  from  other  organic  matter,  are  known  as 
hyaline  casts;  where  they  are  darker  in  color  and  more  solid 
they  are  described  as  waxy  casts.  Hyaline  casts  are  found 
in  all  disorders  of  the  kidneys,  and  in  various  other  con- 
ditions, and  may  also,  to  some  extent,  be  present  in  health. 
Waxy  casts  are  usually  considered  significant  of  an  ad- 
vanced chronic  disease  of  the  kidneys  known  as  paren- 
chymatous  nephritis. 


Fig.  61. — Centrifugal  machine. 


276      EXAMINATION   OF   VOMITUS,   SPUTUM,    EXCRETA 

The  casts  may  contain  blood-cells,  pus-cells,  epithelial 
cells,  or  bacteria,  according  to  the  condition  of  the  diseased 
kidney,  and  are  then  described  as  blood,  pus,  epithelial, 
or  bacterial  casts.  Epithelial  casts  occur  in  the  early  stages 
of  acute  inflammation  of  the  kidneys;  in  the  later  stages  the 
epithelial  lining  of  the  tube  becomes  broken  down  into 
debris,  and  casts  showing  this  debris  are  known  as  granular 
casts.  In  chronic  nephritis  epithelial  degeneration  is 
frequently  shown  by  the  presence  of  oil-drops  in  the  casts, 
which  are  then  described  as  fatty  or  oily  casts. 

Crystals. — The  crystals  of  uric  acid  and  the  various 
salts  in  the  urine  may  be  studied  under  the  microscope,  the 
presence  of  the  different  varieties  being,  in  many  instances, 
of  diagnostic  value.  For  example,  certain  crystals  formed 
by  the  union  of  the  phosphates  with  ammoniomagnesium 
and  known  as  triple  phosphates,  occur  only  in  decomposed 
urine;  if,  therefore,  they  are  found  in  urine  when  freshly 
voided,  their  presence  indicates  that  the  urine  is  decom- 
posed while  in  the  bladder  and  points  to  cystitis. 

Blood  and  Pus. — The  presence  of  blood  or  pus  in  the 
urine  is  determined  with  the  microscope  by  detecting  the 
red  and  white  corpuscles  of  the  blood  and  the  leukocytes 
which  form  the  pus-cells. 

The  microscopic  examination  of  urine  can  be  carried 
out  only  by  an  expert  in  the  use  of  the  microscope.  The 
above  brief  description  is,  however,  necessary  for  an  in- 
telligent understanding  of  the  results  attained  by  the 
examination. 

Chemical  Examination. — For  a  chemical  examination  of 
urine  a  tray  should  be  arranged  containing  the  following: 

Urinometer  and  glass. 

Red  and  blue  litmus  paper. 

Filter-paper. 

Pipet. 

Alcohol  lamp. 

Conic  glass. 

Test-tubes. 

Test  solutions — nitric  acid,  acetic  acid,  sulphate  of  copper, 
liquor  potassa>,  tincture  of  yuaiacum,  and  ozonic  etherf 
about  half  an  ounce  of  each  in  small  bottles. 


EXAMINATION   OF  THE    URINE  277 

The  chemical  examination  will  determine  the  presence 
and  nature  of  abnormal  substances  in  solution.  The  find- 
ing of  one  substance  does  not  preclude  the  presence  of 
another.  The  substances  sought  for  are  an  excess  of 
urates  or  phosphates,  albumin,  blood,  pus,  excess  of 
mucus,  chyle,  and  sugar. 

The  examination  should  proceed  methodically,  step 
by  step,  always  in  the  same  order,  so  that  no  point  is  over- 
looked. 

1.  Observe  the  specimen  carefully,  its  color,  its  clearness, 
and  note  the  presence   and   character   of   any   deposit; 
urine  that  is  not  clear  is  described  as  cloudy. 

2.  Take  the  specific  gravity. 

3.  Test  the  reaction. 

4.  Boil  the  specimen. 

5.  Apply  the  reactionary  agent  or  test. 

Specific  Gravity. — To  take  the  specific  gravity  a  urin- 
ometer  and  a  glass  vessel  of  sufficient  size  for  the  urinonv 
eter  to  float  in  it  are  required.  A  cylindric  glass  about  1^ 
inches  in  diameter,  with  a  capacity  of  5  ounces,  is  generally 
used.  The  urinometer  consists  of  a  dial  marked  off  in 
degrees,  much  like  the  dial  of  a  thermometer,  attached  to 
a  small  air-chamber,  the  latter  weighted  by  a  bulb  of  mer- 
cury ;  placed  in  a  fluid,  the  instrument  floats  with  the  dial 
upright. 

The  glass  filled  with  the  urine  to  be  examined,  the  urin- 
ometer is  floated  in  the  urine,  taking  care  that  it  floats 
freely  and  does  not  touch  the  bottom  or  sides  of  the  glass. 
The  number  on  the  dial  immediately  on  the  level  of  the 
urine  indicates  the  specific  gravity  of  urine  as  compared  to 
water,  the  weight  of  which,  as  said  above,  is  taken  as  the 
unit  of  comparison. 

Reaction. — Red  or  blue  litmus  paper  or  yellow  turmeric 
paper  may  be  used  to  test  the  reaction  of  the  urine.  The 
paper  is  touched  to  the  urine  for  examination,  and  any 
change  compared  with  the  unaltered  paper. 

Acid  urine  turns  blue  litmus  paper  red  and  intensifies  the 
color  of  the  red  litmus  paper. 

Alkaline  urine  turns  red  litmus  paper  blue  and  intensifies 
the  color  of  the  blue  litmus  paper. 


278      EXAMINATION   OF   VOMITUS,    SPUTUM,    EXCRETA 

Neutral  urine  does  not  alter  either  red  or  blue  litmus 
paper. 

Add  urine  turns  yellow  turmeric  paper  brown. 

Boiling. — In  boiling  urine  the  object  is  to  dissolve  those 
substances  which  are  soluble  by  heat,  and  to  cause  those 
to  appear  which  are  visible  only  when  coagulated,  as  by 
heat.  Boiling  does  not  alter  the  appearance  of  normal 
urine. 

Two-thirds  of  the  test-tube  should  be  filled,  and  only 
the  upper  half  heated,  in  order  that  the  heated  and  un- 
heated  portions  may  be  compared  and  delicate  differences 
observed.  The  tube  should  be  held  by  the  lower  end 
slantwise  above  an  alcohol  flame,  with  the  open  end  turned 
away  from  the  operator  to  avoid  accidents. 

A  substance  which  appears  in  the  urine  on  testing  is 
called  a  precipitate,  one  visible  before  testing,  a  deposit. 
A  precipitate  is  said  to  be  formed  or  thrown  down. 

Urine  containing  excess  of  urates  is  clear  when  voided, 
and  on  cooling  becomes  thick,  with  a  dense  orange  cloud. 
It  is  highly  colored  and  strongly  acid.  Usually  it  has  a 
deposit  of  pink  pigment  which  stains  the  sides  of  the  vessel. 
On  heating  the  urine  the  cloudiness  disappears,  leaving  the 
specimen  clear,  urates  being  soluble  by  heat. 

Urates  (the  salts  of  uric  acid)  are  present,  it  will  be  re- 
membered, in  normal  urine  in  small  quantities.  They 
are  increased  in  quantity  in  all  conditions  in  which  urine 
is  concentrated  or  scanty;  such,  for  example,  as  in  fever- 
ish conditions,  after  free  perspiration,  and  in  conditions 
associated  with  uric  acid,  such  as  gout. 

Excess  of  Phosphates. — Phosphates  may  be  present  in 
either  clear  or  cloudy  urine,  and  are  invisible  before  heating. 
The  urine  is  either  neutral  or  alkaline,  as  phosphates  are 
soluble  by  acid.  On  heating  the  urine  it  is  observed  to 
grow  denser,  and  a  little  cloud  appears  in  the  heated  por- 
tion. A  few  drops  of  acetic  acid  or  one  or  two  drops  of 
nitric  acid  are  gently  added,  and  the  specimen  lightly 
shaken.  If  the  cloud  is  composed  of  phosphates,  the  acid 
will  dissolve  it  and  the  urine  become  clear  again.  Like 
urates,  phosphates  are  found  in  normal  urine,  and  their 
presence  in  excess  does  not  indicate  disease  of  the  urinary 


EXAMINATION   OF   THE   URINE  279 

tract.  Patients  suffering  from  chronic  debility,  diseases 
such  as  rickets,  dyspepsia,  etc.,  frequently  have  an  excess 
of  phosphates  in  the  urine. 

Albumin. — Albumin  may  be  found  in  urine  (albumin- 
uria),  either  clear  or  cloudy,  acid  or  alkaline,  or  containing 
any  other  abnormal  substances,  As  a  rule,  the  specific 
gravity  is  very  low — below  1008.  Albumin  is  always 
present  in  urine  containing  either  blood  or  pus. 

If  the  suspected  urine  is  cloudy,  it  should  be  passed 
through  filter-paper  before  testing. 

If  the  reaction  is  alkaline,  the  specimen  should  be  made 
slightly  acid  by  the  addition  of  a  few  drops  of  acetic  acid 
before  testing. 

On  heating,  a  cloud  similar  to  that  of  the  phosphates  is 
seen,  caused  by  the  coagulation  of  the  albumin.  On  add- 
ing acetic  acid  or  nitric  acid,  however,  the  cloud,  instead 
of  clearing,  becomes  denser,  and  a  precipitate  is  formed 
by  the  coagulation  of  the  albumin,  which  will  remain 
on  cooling.  Where  urates  and  albumin  exist  in  the  same 
specimen,  two-thirds  of  the  test-tube  may  be  filled  with 
the  urine;  the  middle  third  of  the  column  may  be  warmed 
until  the  urates  are  dissolved,  and  the  upper  third  only 
brought  to  boiling-point.  There  will  then  be  seen  the 
lower  third  of  urine  turbid  from  the  presence  of  urates,  the 
middle  third  of  clear  urine,  and  the  upper  third  cloudy 
with  a  precipitate  of  albumin. 

The  presence  of  albumin  may  also  be  detected  by  the 
nitric  acid  test,  also  known  as  Heller's  test.  A  small 
quantity  of  nitric  acid  is  taken  in  a  test-tube,  and  on  it  is 
floated  a  column  of  urine  by  gently  sliding  the  urine  down 
the  side  of  the  test-tube.  Where  the  urine  rests  on  the 
nitric  acid,  a  white  ring  will  form  if  albumin  is  present. 
Urine  containing  an  excess  of  urea  and  no  albumin  will 
also  show  a  ring  with  this  test.  The  specific  gravity  of 
the  urine  will,  however,  be  high,  1025  to  1030,  instead  of 
low,  as  in  albuminous  urine;  the  ring  does  not  form  exactly 
over  the  urine,  is  not  pure  white,  is  less  regular  in  shape, 
and  may  be  dispersed  by  boiling. 

An  estimate  of  the  amount  of  albumin  present  may  be 
made  by  using  Esbach's  albuminometer.  This  is  a  test-tube 


280      EXAMINATION   OF   VOMITUS,    SPUTUM,   EXCRETA 


with  the  lower  part  graduated  into  percentages.  The  urine 
is  poured  in  up  to  a  line  marked  U.  The  reactionary  agent 
(Esbach's  solution  of  picric  and  citric  acids)  is  added  to  a 
line  marked  R.  The  tube  is  corked  with  a  rubber  stopper, 
and  the  specimen  left  for  twenty-four  hours,  at  the  end  of 
which  time  the  albumin  may  be  seen  precipitated  at  the 
bottom  of  the  tube,  and  the  percent- 
age read  off  at  the  graduated  marks. 
Albumin  in  the  urine  is  always  a 
serious  condition,  and  usually  points 
to  inflammation  or  disease  of  the 
kidneys  unless  accounted  for  by  blood 
or  pus  in  the  urine,  which  may  be 
present  from  various  causes  not  neces- 
sarily associated  with  the  kidneys. 
Albuminuria  is  found  in  all  forms  of 
kidney  disease  with  the  exception  of 
chornic  interstitial  nephritis,  where  it 
is  frequently  entirely  absent.  It  is  a 
common  complication  of  the  acute 
fevers,  especially  scarlet  fever  and 
diphtheria,  and  is  frequently  found 
associated  with  heart  disease  and 
pneumonia,  due,  it  is  considered,  to 
alteration  in  the  blood-pressure.  Pres- 
sure from  tumors  or  inflammatory 
processes  from  neighboring  structures 
may  also  cause  albuminuria,  or  the 
condition  may  arise  from  deterioration  in  the  quality  of 
the  blood,  as  in  the  serious  anemias. 

Poisoning  by  the  irritant  poisons,  which  have  an  irritat- 
ing effect  upon  the  kidneys,  is  also  a  cause  of  albuminuria. 
Blood. — Blood  in  the  urine  (hematuria)  may  come  from 
the  kidneys  or  from  any  part  of  the  urinary  tract.  It  may 
be  present  in  any  quantity  from  an  amount  invisible  to 
the  naked  eye  to  a  quantity  sufficient  to  give  the  urine 
the  appearance  of  bright-red  blood ;  in  this  latter  condition 
the  amount  of  urine  excreted  is  small. 

When  from  the  kidney,  it  is  intimately  mixed  with  the 
urine,  and  in  small  quantities  gives  the  urine  a  smoky 


Fig.  62.— Esbach's 
albuminometer,  im- 
proved form. 


EXAMINATION    OF  THE   URINE  281 

appearance.  On  standing,  a  deposit  somewhat  like  beef- 
tea  may  be  formed.  The  presence  of  blood  is  best  deter- 
mined by  the  appearance  of  the  urine  and  by  microscopic 
examination.  A  chemical  test,  however,  may  be  made 
in  the  following  manner: 

To  a  dram  of  unboiled  urine  in  a  test-tube  add  one  or 
two  drops  of  tincture  of  guaiacum  without  shaking;  float 
on  the  top  an  excess  of  ozonic  ether;  if  blood  is  present,  a 
bright,  sapphire-blue  ring  should  appear  at  the  juncture 
of  the  urine  and  the  ozonic  ether. 

Hematuria  may  be  present  in  acute  inflammations  or 
diseases  of  the  kidney,  bladder,  or  urethra.  It  may  be 
caused  by  injuries  to  any  part  of  the  genito-urinary  tract, 
as  from  the  presence  of  calculi  or  from  difficult  catheteriza- 
tion.  It  may  result  from  operations  on  the  genito-urinary 
tract,  or  from  injuries  to  neighboring  structures,  as,  for 
example,  a  fracture  of  the  pelvis,  in  which  accident  the 
bladder  is  frequently  indirectly  injured.  Bleeding  from 
the  urethra  occurs  at  the  beginning  of  micturition; 
when  from  the  bladder,  at  the  end.  The  rest  of  the  urine 
in  either  case  may  be  clear.  Blood  in  the  urine  is  always  a 
symptom  of  importance. 

Pus. — Either  pus  or  excessive  mucus  gives  to  the 
urine  an  opaque,  milky,  greenish-yellow  appearance  and 
an  alkaline  reaction.  Unlike  urine  turbid  from  the 
presence  of  urates,  this  specimen  is  cloudy  when  first 
voided.  Like  blood,  the  presence  of  pus  is  determined 
best  by  the  microscope  and  the  appearance  of  the  urine. 

To  make  a  chemical  test  the  specimen  should  stand  until 
the  deposit  settles ;  the  more  fluid  part  may  then  be  poured 
off,  the  deposit  collected  by  a  pipet  and  placed  in  a  test- 
tube.  To  this  is  added  an  equal  quantity  of  liquor 
potassse.  If  the  deposit  is  mucus,  it  will  break  up  into 
flocculent  particles;  if  it  is  pus,  it  will  form  a  lumpy, 
gelatinous  mass. 

Pus  in  the  urine  (pyuria)  arises  from  a  suppurative  con- 
dition of  some  part  of  the  genito-urinary  tract,  or  from 
abscesses  from  adjacent  structures  opening  into  the  tract. 
When  from  the  kidneys,  the  pus  is  intimately  mixed  with 
the  urine. 


282      EXAMINATION   OF   VOMITUS,    SPUTUM,   EXCRETA 

Mucus. — Mucus  is  present  in  large  quantities  in  catar- 
rhal  conditions  of  the  bladder. 

Chyle. — Chyle  in  the  urine  (chyluria)  is  rarely  met  with, 
except  in  patients  suffering  from  the  filaria  sanguinis 
hominis,  a  small,  thread-like  worm  which  infects  the  lymph- 
atics, causing  occlusion  of  the  lymphatic  ducts.  The 
condition  is  rarely  seen  except  in  tropical  climates.  The 
chyle,  which  should  be  carried  off  by  the  thoracic  duct, 
is  then  frequently  found  in  the  urine.  The  urine  has  a 
milky  appearance,  due  to  the  finely  emulsified  fat;  fre- 
quently it  may  have  a  pinkish  color,  from  the  presence 
of  blood.  That  the  milkiness  is  due  to  the  fat  may  be 
proved  by  adding  ether  to  a  small  quantity  of  the  urine 
in  a  test-tube.  The  ether  will  dissolve  the  fat,  and  the 
milkiness  disappears. 

Sugar. — The  sugar  present  in  urine  (glycosuria)  in 
disease  is  the  kind  known  as  grape-sugar,  or  dextrose 
(one  of  the  glycogens),  and  is  a  normal  constituent  of 
the  blood.  The  urine  is  pale,  of  high  specific  gravity, 
1030  to  1050,  and  passed  in  enormous  quantities.  Grape- 
sugar  has  the  property  of  turning  blue  oxid  of  copper  into 
orange  suboxid.  Copper,  then,  is  used  to  detect  its  pres- 
ence. It  may  be  employed  in  different  ways. 

Trommer's  Test. — To  a  small  quantity  of  urine  in  a  test- 
tube  add  half  the  amount  of  liquor  potassse,  then  slowly 
a  few  drops  of  sulphate  of  copper,  until  the  mixture  is 
blue;  heat  over  an  alcohol  lamp.  If  sugar  is  present,  an 
orange-red  precipitate  will  be  formed. 

Fehling's  test  is  a  modification  of  the  above.  Take 
equal  parts  of  liquor  potassse  and  solution  of  sulphate  of 
copper  and  heat  in  a  test-tube.  In  a  second  test-tube 
take  a  corresponding  volume  of  urine  and  heat  it,  then  add 
the  urine  to  the  solution  by  sliding  it  gently  down  the  sides 
of  the  test-tube.  If  sugar  is  present,  an  orange-red  color 
will  appear. 

Bottger's  Test. — A  different  test  for  sugar  may  be  made 
by  adding  to  the  urine  an  equal  quantity  of  liquor  potassse 
with  a  few  grains  of  subnitrate  of  bismuth,  and  boiling. 
If  sugar  is  present,  the  mixture  turns  black.  To  use  this 
test,  the  urine  must  be  free  from  albumin.  Albumin 


EXAMINATION   OF  THE    URINE  283 

contains  sulphur,  which,  if  heated  in  the  same  way  with 
bismuth,  will  form  the  black  sulphurate  of  bismuth. 

Quantitative  Test  for  Sugar. — The  proportion  of  sugar 
may  be  approximately  estimated  by  the  fermentation 
test.  Take  the  specific  gravity,  and  then  place  the  urine 
in  a  corked  bottle  with  a  small  piece  of  German  yeast, 
leaving  a  hole  in  the  cork.  Keep  the  specimen  in  a  warm 
place  or  even  temperature  for  twenty-four  hours,  and  then 
test  it  for  sugar.  If  all  trace  of  sugar  has  disappeared, 
again  take  the  specific  gravity.  Subtract  the  present 
specific  gravity  from  that  before  fermentation  took  place, 
and  the  difference  in  the  result  represents  approximately 
the  number  of  grains  of  sugar  in  each  ounce  of  urine. 
This  test  must  be  made  from  the  collected  amount  passed 
in  the  twenty-four  hours. 

Sugar  is  persistently  present  in  the  urine  in  patients 
suffering  from  diabetes  mellitus.  It  may  also  be  tempor- 
arily seen  after  the  ingestion  of  a  large  proportion  of  sac- 
charine food,  in  chloroform  poisoning,  in  pregnancy,  and 
in  some  infectious  and  nervous  disorders. 

Bile. — Bile  in  the  urine  (chylurid)  is  recognized  by  the 
dark,  porter-like  color  it  gives  the  urine.  Urine  containing 
bile  will  stain  linen  yellow.  Its  presence  may  be  demon- 
strated by  dropping  a  few  drops  of  the  urine  from  a  pipet 
on  a  white  tile,  and  adding  a  few  drops  of  nitric  acid. 
As  the  urine  and  the  nitric  acid  mix,  a  play  of  colors  is  no- 
ticed, of  which,  to  demonstrate  bile,  green  must  be  one. 

Indican. — The  presence  of  indican  in  the  urine  is  fre- 
quently of  diagnostic  importance.  Indican  is  the  product 
of  indol,  which  is  produced  as  a  result  of  bacterial  decom- 
position of  food  that  has  been  long  retained  in  the  small 
intestine.  A  small  quantity  of  urine  is  mixed  in  a  test- 
tube  with  an  equal  quantity  of  hydrochloric  acid,  to  which 
is  added,  drop  by  drop,  a  mixture  known  as  Labarraque's 
solution,  or  liquor  sodse  chlorinatse  (carbonate  of  soda  and 
chlorinated  lime).  If  indican  is  present,  the  mixture  turns 
an  indigo-blue  color. 

Gravel.— A  deposit  of  fine  sand,  sometimes  reddish  in 
color,  is  not  infrequently  found,  usually  in  strongly  acid 
urine.  The  urine  is  voided  with  pain.  The  deposit  con- 


284      EXAMINATION   OF   VOMITUS,    SPUTUM,    EXCRETA 

sists  of  small  urinary  calculi,  composed  of  the  salts  of 
uric  acid,  and  is  not  soluble  by  heat,  as  is  the  ordinary 
pinkish  deposit  of  urine  containing  excessive  urates. 
This  sand  deposit  is  usually  termed  gravel.  Either  per- 
sistent hyperacidity  or  alkalinity  may  result  in  the  for- 
mation of  calculi. 

The  urine  of  patients  with  typhoid  fever  should  give 
what  is  known  as  Ehrlich's  diazo-reaction. 

To  make  this  test  two  solutions  are  required.  One 
is  composed  of  sulphanilic  acid,  5;  hydrochloric  acid 
(pure),  50;  water,  1000;  the  second  contains  sodium  nitrate, 
0.5,  to  water,  100.  The  two  are  mixed  together  in  a 
test-tube  in  the  proportion  of  50  c.c.  of  the  hydrochloric 
acid  solution  and  1  c.c.  of  the  sodium  nitrate  solution; 
an  equal  volume  of  urine  is  added  to  the  mixed  solution, 
and  finally  1  c.c.  of  ammonia  water.  The  whole  is  shaken 
until  it  froths.  The  reaction  is  present  if  the  urine,  includ- 
ing the  foam,  turns  rose-red.  The  reaction  has  also  been 
noticed  in  pneumonia,  septicemia,  and  other  conditions. 

Chemical  tests  may  also  be  used  to  test  the  proportion 
of  urea  in  the  urine.  The  presence  of  urea  may  be  demon- 
strated by  adding  to  a  few  drops  of  urine  on  a  glass  slide 
a  drop  or  two  of  nitric  acid.  The  acid  will  unite  with  the 
urea,  forming  crystals  of  nitrate  of  urea.  Oxalic  acid  may 
be  used  instead  of  nitric  acid  in  the  same  manner.  Unless 
the  specimen  contains  urea  in  excess,  the  urine  must  be 
allowed  partially  to  evaporate  by  exposure  before  the  acid 
is  added.  To  estimate  the  quantity  of  urea,  there  are  sev- 
eral complicated  processes  and  special  apparatus.  The 
simplest  one  is  Fowler's  hypochlorite  test  for  urea.  The 
process  is  as  follows: 

"  Add  to  one  volume  of  the  urine  seven  volumes  of 
Labarraque's  solution  of  chlorinated  soda. 

"  Shake  the  jar  containing  the  mixture  thoroughly 
and  stand  it  aside  for  two  hours  (shaking  occasionally}, 
when  the  urea  will  have  been  decomposed.  Now  take  the 
specific  gravity  of  the  quiescent  fluid. 

"  Ascertain  the  specific  gravity  of  the  mixture  of  urine 
and  Labarraque's  solution  before  decomposition.  To  do 
this  multiply  the  specific  gravity  of  the  pure  Labarraque's 


EXAMINATION   OF   THE    URINE  285 

solution  by  7,  add  this  to  the  specific  gravity  of  the  pure 
urine,  and  divide  by  8.  The  result  is  the  specific  gravity 
of  the  mixed  fluid.  From  this  subtract  the  specific  gravity 
of  the  quiescent  mixture  after  decomposition  of  the  urea, 
multiply  the  difference  by  0.77,  and  the  result  is  the 
percentage  of  urea  "  (A.  A.  Stevens,  "  Manual  of  Med- 
icine "). 

In  hospital  work  the  examination  of  urine  is  carried 
on  in  the  laboratories,  and  is  rarely  part  of  a  nurse's 
duties.  In  the  small  hospitals,  where  there  is  no  resident 
medical  staff,  and  in  private  practice,  she  is,  however, 
frequently  required  to  undertake  certain  processes  of  the 
chemical  examination.  Before  all  operations,  for  example, 
the  urine  of  patients  is  examined  to  determine  especially 
the  presence  of  albumin  or  sugar.  There  are  several 
reasons  for  this  examination,  of  which  we  may  note  the 
two  principal.  Ether  is  highly  irritating  to  the  kidneys; 
patients,  then,  already  suffering  from  inflammation  of  the 
kidneys,  as  suggested  by  the  presence  of  albumin,  run  an 
added  risk  in  undergoing  an  operation  where  anesthesia 
is  necessary.  In  this  case  chloroform  is  sometimes  sub- 
stituted as  being  less  irritating,  or  the  operation  may  be 
postponed  until  the  kidneys  are  in  a  healthier  condition. 
If  the  operation  is  performed,  the  after-treatment  will  be 
qualified  by  the  condition  of  the  kidneys.  Patients  with 
glycosuria  are  in  most  instances  suffering  from  diabetes 
mellitus.  In  this  condition  the  tissues  are  deficient  in 
healing  properties,  and  wounds  are  liable  to  be  followed  by 
gangrene;  patients,  therefore,  with  glycosuria  are  not 
considered  favorable  subjects  for  operative  proceedings 
when  such  can  be  avoided. 

The  examinations  of  urine  commonly  asked  of  a  nurse 
are  to  ascertain  the  specific  gravity  and  the  reaction  of  the 
specimen,  and  to  apply  the  tests,  as  indicated  above,  for 
urates,  phosphates,  albumin,  and  sugar.  Every  nurse 
ought  to  be  able  to  carry  out  these  simple  tests  accurately. 
Where  an  extraneous  substance  is  found  or  suspected,  the 
same  specimen  should  be  kept  for  verification  by  the 
doctor,  as  it  does  not  always  follow  that  the  substance  may 
be  persistently  present,  or  present  in  the  same  proportion. 


CHAPTER  VIII 
BANDAGES  AND  SPLINTS 

Bandages — Rests;  Spiral,  Reverse,  Figure-of-8,  Spica,  Tort- 
uous— Special  Bandages — Heel,  Foot,  Hand,  Stump,  Eye,  Barton, 
Neck  and  Brow,  Breast,  Capeline,  Velpeau,  T-,  Jaw,  Many-tail, 
Binder,  Y-bandage,  Handkerchief — Slings — Plaster-of -Paris,  Sayres' 
Jacket  and  Jury-mast;  Starch;  Silicate  of  Soda;  Wax — Splints — 
Applying,  Pressure-sore;  Straight,  Back,  and  Angular  Splints;  Frac- 
ture-box— Special  Splints — Bond,  Levis,  Thomas,  Dupuytren, 
Hodgen;  Inclined  Plane;  Gooches'  Coaptation  Splinting;  Poroplastic 
Felt;  Extensions,  Restraint;  Bradford  Frame;  Sand-bags;  Cradles; 
Strapping — Applying;  Special,  for  Ribs,  Clavicle,  Ulcers,  Joints. — 
Knots — Granny,  Reef,  Surgeon's,  Clove-hitch. 

BANDAGES 

IN  surgical  work  bandages  are  in  constant  use,  and  all 
nurses  should  know  how  to  apply  neatly  and  adequately 
the  proper  bandage  for  the  proper  circumstance.  Band- 
aging is  most  satisfactorily  taught  in  classes;  dummy 
limbs,  sand-bags,  clubs,  etc.,  may  be  used  for  the  individ- 
ual practice;  in  class  the  pupils  should  learn  on  each  other, 
or  on  a  convalescent  patient,  where  one  is  found  willing  to 
serve. 

Bandages  are  used  for  support,  to  apply  pressure,  or  to 
retain  splints,  dressings,  and  applications  in  their  place. 

Two  varieties  are  used — the  roller  and  the  handkerchief. 
Roller  bandages  are  made  of  unbleached  muslin,  crinolin, 
gauze,  flannel,  or  rubber.  Crinolin  bandages  may  be 
stiffened  with  plaster-of-Paris,  starch,  silicon,  or  wax. 

Roller  bandages  are  cut  in  lengths  of,  usually,  7  to  9 
yards,  and  in  widths  of  from  1  to  6  inches. 

A  different  width  is  used,  for  convenience,  for  different 
parts  of  the  body,  thus: 

Leg,    width,  3        inches;  length,  9  yards. 


Arm, 

Head,  "  2| 

Eye,  "  2 

Finger,  "  1-lj 

Ribs,  "  4-6 


286 


BANDAGES  287 

Bandages  should  be  rolled  tightly  and  evenly  and  all 
unravelings  closely  cut  away.  To  keep  the  edges  even, 
bandages  of  muslin,  crinolin,  and  flannel  are  torn  from  the 
piece.  Gauze  bandages  are  usually  obtained  ready  cut 
and  rolled  by  machinery,  but  if  to  be  prepared  by  hand,  the 
gauze  must  be  carefully  cut  by  the  thread.  A  bandage 
roller  is  generally  used  to  roll  bandages,  and  makes  a 
firmer  bandage  than  a  hand-rolled  one  (Fig.  63).  Gauze 
bandages  are  used  to  apply  dressings,  being  cool  and  clean. 
Muslin  bandages,  being  stouter,  are  better  for  applying 
splints,  etc.,  or  where  support  is  required.  A  crinolin  band- 


Fig.  63. — Hand  roller-bandage  machine  (Fowler). 

age,  stiffened  by  one  or  other  method,  is  practically  both 
splint  and  bandage,  and  is  used  to  insure  immobility.  Pres- 
sure may  be  applied  by  a  flannel  bandage  or  by  a  muslin 
bandage  applied  over  an  even  layer  of  sheet  cotton. 
Even  pressure  over  the  course  of  a  vein,  as  in  the  treat- 
ment of  varicose  veins,  is  applied  by  the  rubber  Esmarch 
bandage  directly  on  to  the  surface  of  the  skin. 

Position  for  Bandaging. — Before  applying  a  bandage  the 
patient  must  be  placed  in  a  comfortable  position,  with  the 
part  to  be  bandaged  supported  so  that  it  can  be  easily 
reached  and  kept  immovable  without  undue  fatigue. 
Rests  for  the  pelvis  or  the  heel  are  obtained  in  metal  or 
wood.  A  U-shaped  piece  of  wood  on  a  stout  column 


288  BANDAGES   AND   SPLINTS 

fitted  on  to  a  solid  base  is  easily  made,  and  forms  a  support 
for  the  ankle  while  the  leg  is  elevated  for  bandaging. 
For  the  pelvis,  the  supporting  piece  should  be  flat,  about 
6  inches  long  and  4  wide,  fixed  at  right  angles  to  the  sup- 
porting column.  Sand-bags  or  pillows  are  practical 
substitutes  if  a  rest  is  not  at  hand. 

To  support  a  leg  by  the  hand,  it  should  be  lifted  with  one 
hand  under  the  ankle  and  the  other  grasping  the  toes, 
keeping  the  foot  at  right  angles  to  the  leg.  Speaking 
surgically,  the  leg  is  that  portion  of  the  lower  extremity 
between  the  knee  and  the  ankle. 


Fig.  64. — Leg  rest.  Fig.  65. — Rest  for  pelvis. 

To  support  an  arm  the  hand  is  clasped  by  one  hand,  the 
arm  extended,  and  the  other  hand  placed  below  the 
elbow. 

To  support  the  head,  the  shoulders,  or  the  pelvis  by  hand, 
the  nurse  should  place  her  elbow  firmly  on  the  bed  and 
support  the  part  with  the  palm  of  the  hand.  This  position 
can  be  retained  longer  than  any  other  attitude  of  lifting 
without  fatigue  or  faintness,  and  keeps  the  part  steadier. 

Rules. — In  bandaging  (roller)  a  few  rules  must  be 
remembered: 

1.  Stand  directly  opposite  the  part  to  be  bandaged  and 
bandage  away  from  yourself. 

2.  Bandage  from  the  inner  to  the  outer  surface  of  a 
limb  and  from  below  upward. 

3.  Fix  the  bandage  with  the  first  turn;  cover  with  each 
subsequent  turn  two-thirds  of  the  turn  below. 

4.  Make  no  turn  or  knots  over  a  bony  prominence. 

5.  Unroll  the  smallest  possible  portion  of  the  bandage 


BANDAGES 


289 


only,  and  keep  the  rolled  portion  firmly  between  the 
fingers  and  thumb. 

6.  Finish  the  bandage  on  the  outside  of  a  limb;  use  a 
safety-pin  run  through  the  long  axis  of  bandage;  a  body 
bandage  is  pinned  in  front,  and  a  head  bandage  over  the 
temple. 

To  the  second  rule  there  are  two  exceptions:  (1)  In 
fracture  of  the  femur  the  deformity  is  eversion;  the  bandage 
is  applied  from  the  outer  to  the  inner  surface  to  correct  it. 
(2)  A  roller  applied  over  the  ribs  is  applied  from  above 
downward. 


Fig.  66. — Spiral  reversed  bandage  (Stoney). 


Fig.  67. — Spiral  reversed  bandage  of  upper 
extremity  (DaCosta). 


Fig.  68. — Spiral 
reversed  bandage 
of  lower  extremity 
(DaCosta). 


To  rule  3,  the  eye  bandage  and  some  form  of  head  band- 
age are  the  exception;  each  turn  in  these  bandages  com- 
pletely covers  the  lower  turn. 

A  roller  bandage  is  applied  in  three  ways:  the  simple 
spiral,  the  reverse  spiral,  and  the  figure-of-eight,  of  which 
latter  there  are  several  modifications. 

The  simple  spiral  is  applied  by  rolling  the  bandage 
obliquely  round  the  member,  each  turn  covering  two- 
thirds  of  the  turn  below. 

The  reverse  spiral  is  employed  where,  owing  to  the  shape 
of  the  member,  the  simple  spiral  will  not  stay  in  place. 
At  each  round  of  the  bandage  a  sharp  turn  or  fold  is  made 
in  the  width  of  the  bandage,  as  though  it  were  going  to  be 

19 


BANDAGES   AND   SPLINTS 

cut  on  the  bias;  this  gives  the  bandage  an  elasticity  and 
enables  it  to  fit  more  closely.  To  make  the  turn  neatly, 
each  exactly  above  the  lower  turn,  the  lower  margin  of 
the  bandage  is  fixed  by  the  thumb  of  one  hand  while  the 
turn  is  made.  In  bandaging  the  leg  the  sharp  shin  bone 
can  be  taken  as  a  guide,  and  the  turn  made  to  the  outside 
of  the  bone.  For  the  upper  extremity,  the  arm  should  be 
held  with  the  back  of  the  hand  uppermost,  and  the  turns 
made  exactly  in  the  center. 

The  figure-of-8  bandage  is  used  over  joints  and  in 
the  application  of  splints  and  dressings.  It  consists  of  a 
series  of  double  loops  round  a  limb  or  joint,  starting  in 


Fig.  69. — Figure-of-8  bandage  Fig.  70. — Posterior  figure-of-8 

(Stoney).  of  both  shoulders  (DaCosta). 

front,  carried  obliquely  upward  round  the  limb  or  joint 
behind,  and  brought  down  again  in  front,  crossing  the 
lower  turn  so  made.  Each  crossing,  for  appearance  sake, 
is  made  directly  above  the  one  below. 

Where  the  joint  is  at  right  angles  to  the  body,  as  in  the 
shoulder  or  the  hip,  one  loop  of  the  figure-of-8  is  much 
larger  than  the  other,  but  the  principle  of  double  loops 
crossing  in  front  is  the  same.  Such  a  bandage  is  called  a 
spica. 

The  shoulder  spica  is  fixed  first  by  a  few  spirals  round 
the  upper  arm.  A  loop  is  then  taken,  passing  across  the 
back,  under  the  opposite  axilla,  and  returning  over  the 
chest,  is  crossed  on  the  outer  surface  of  the  upper  arm; 
the  smaller  loop  passes  round  the  arm.  The  turns  are 
continued  until  the  point  of  the  shoulder  is  well  covered. 


BANDAGES 


291 


The  Pelvic  Spica. — In  the  same  way  the  pelvic  spica 
bandage  has  the  smaller  loop  round  the  thigh,  and  the 
larger  loop  round  the  pelvis.  The  turns  cross  in  front  of 
the  thigh  toward  the  outer  side.  It  is  fixed  more  securely 


Fig.  71. — Spica  of  the  shoulder 
(DaCosta). 


Fig.    72. — Spica    of    the    groin 
(DaCosta). 


by  taking  the  first  turn  round  the  pelvis.  Where  both 
shoulders  or  both  hips  are  to  be  bandaged,  the  double 
spica  is  used.  The  large  loop  round  the  trunk  is  inter- 
rupted to  take  a  second  loop  round  the  opposite  joint; 
the  loops  round  each  joint  are  made  alternately,  the  band- 
age forming  the  loop  round  the  body'  between  either 
joint. 


Fig.  73. — Figure-of-8  bandage 
of  the  instep  (DaCosta). 


Fig.  74. — Spica  of  the  instep 
(DaCosta). 


The  foot  is  bandaged  by  a  series  of  figure-of-8  loops 
passing  round  the  foot  and  round  the  ankle.  The 
first  turn  is  fixed  round  the  ankle,  and  the  bandage  then 
brought  round  the  roots  of  the  toes,  each  subsequent 
loop  covering  two-thirds  of  the  loop  below  it. 


292 


BANDAGES   AND    SPLINTS 


The  hand  is  bandaged  by  a  series  of  figure-of-8  loops 
passing  alternately  round  the  hand  and  round  the  wrist. 

Bandaging  the  Fingers.— In  bandaging  the  finger  the 
tip  is  covered  by  carrying  the  bandage  to  and  fro  over  the 
tip;  the  folds  so  made  are  held  in  place  until  fixed  by  a 
series  of  simple  spiral  turns.  If  several  fingers  are  to  be 
bandaged  separately,  each  finger  bandage  is  secured  in 
turn  by  a  figure-of-8  loop  round  the  wrist.  Usually  it 
is  more  practical  to  pack  plenty  of  dressing  between  the 
fingers  and  bandage  them  together  with  the  hand,  using 
figure-of-8  loops. 

The  thumb  is  bandaged  with  a  spica,  the  loops  alter- 
nately round  the  wrist  and  round 
the  thumb,  starting  from  the  base. 


Fig.    75.  —  Spica    of 
thumb  (DaCosta). 


Fig.  76. — Tortuous  bandage  for  knee :    a, 
Side  view;  b,  from  above. 


Tortuous  Bandage. — Where  a  joint  is  to  be  kept  flexed, 
a  modification  of  the  figure-of-8  bandage,  known  as  the 
tortuous  bandage,  is  used.  Instead  of  each  turn  cover- 
ing partially  the  turn  below  it,  the  first  turn  is  taken  on 
the  angle  of  the  joint,  and  a  series  of  loops  are  then  made 
alternately  above  and  below  the  first  turn,  which  is  the 
fixed  point.  The  loops  above  the  fixed  point  are  taken  one 
above  the  other,  the  lower  loops  one  below  the  other. 

Bandaging  the  Heel. — In  bandaging  the  heel,  the  tor- 
tuous bandage  is  used.  To  fix  it  a  loop  is  taken  starting 
from  the  outer  malleolus,  passing  below  the  heel,  across 
the  instep,  and  round  the  ankle.  The  first  turn  of  the 
tortuous  bandage  is  then  taken  over  the  point  of  the  heel, 


BANDAGES 


293 


then  below  and  above,  as  many  loops  as  are  necessary  until 
the  heel  is  covered,  the  cross-turns  showing  on  either  side 
of  the  foot.  Practice  is  required  to  bandage  the  heel 
securely  and  neatly. 

Bandaging  a  Stump. — In  bandaging  a  stump  the  end  is 
first  covered  by  carrying  the  bandage  to  and  fro.     The 


Fig.  77. — Method  of  cov- 
ering the  heel. 


Fig.  78. — Recurrent  band- 
age of  a  stump  (DaCosta). 


center  is  taken  as  the  starting-point,  and  the  bandage 
carried  to  right  and  left  alternately,  each  turn  covering 
two-thirds  of  the  turn  next.  The  turns  so  made  are  held 
in  place  by  the  left  hand.  When  the  end  of  the  stump  is 
covered,  the  ends  are  secured  by  a  figure-of-8  bandage  or 
a  simple  spiral  carried  up  as  high  as  necessary. 

An  eye  bandage  should  be 
light  and  firm.  The  bandage  con- 
sists of  alternate  loops  taken,  the 
first  one  round  the  head  at  the 
temples;  the  second,  passing  from 
the  temple  behind  the  head,  under 
the  opposite  ear,  is  brought  up 
over  the  cheek,  covering  the  eye, 
and  crossing  the  root  of  the  nose 
to  the  temple  again.  Some  ocu- 
lists order  pressure  to  be  made 
downward  in  bandaging  the  eye. 
The  second  loop  is  then  applied 
in  reverse  order  from  the  temple 
across  the  eye  and  cheek  and  under  the  ear,  finally 
over  the  back  of  the  head,  to  the  point  from  where  it 


Fig.  79.— Figure-of-8  of 
one  eye  (Stoney) . 


294 


BANDAGES   AND   SPLINTS 


started.  As  a  rule,  in  an  eye  bandage  each  turn  exactly 
covers  the  one  below  unless  a  dressing  has  to  be  covered 
in.  In  this  case  each  head  turn  is  completely  covered, 
while  each  turn  over  the  eye  covers  two-thirds  of  the  one 
below.  Both  eyes  may  be  bandaged  together.  The 
bandage  starts  from  the  right  temple,  is  brought  down  over 
the  left  eye,  under  the  left  ear,  across  the  back  of  the  neck, 
under  the  right  ear,  up  over  the  right  eye,  to  the  left 
temple;  half  a  turn  round  the  head  brings  the  bandage 
back  to  the  right  temple,  from  where  it  starts  again. 
The  turns  cross  over  the  root  of  the  nose;  when  complete, 
a  couple  of  turns  are  taken  round  the  head  to  fix  the 
bandage. 


Fig.  80.— Crossed  figure-of-8 
bandage  of  both  eyes  (DaCosta). 


Fig.  81. — Barton's    bandage,    or 
figure-of-8  of  the  jaw  (DaCosta) . 


Bandaging  the  Jaw. — To  bandage  the  jaw  a  modifica- 
tion of  the  figure-of-8,  known  as  the  Barton  bandage,  is 
used. 

The  first  turn  begins  immediately  below  the  occiput, 
passes  up  the  head  behind  the  right  ear,  and  over  the 
crown  to  the  left  temple;  continuing,  the  bandage  is  carried 
down  the  cheek  in  front  of  the  left  ear,  under  the  chin, 
and  up  the  cheek  in  front  of  the  right  ear,  over  the  crown, 
and  crossing  the  first  turn  back  to  the  starting-point. 
The  second  turn  passes  round  the  back  of  the  neck 
under  the  right  ear,  and  over  the  chin  back  to  the  base  of 
the  occiput.  The  turns  are  repeated  as  often  as  neces- 
sary, each  completely  covering  the  one  below.  The  band- 
age should  finish  on  the  crown. 


BANDAGES  295 

Nape  of  the  Neck. — In  applying  a  dressing  to  the  nape 
of  the  neck  a  figure-of-8  is  applied,  the  loops  alternately 
round  the  neck  and  round  the  brows,  crossing  at  the 
occiput.  If  the  dressing  covers  the  ears  or  submaxil- 
lary  glands,  the  loops  are  made  alternately  from  the 
nape  round  the  brows  and  from  under  the  chin,  over  the 
crown,  half  a  turn  being  taken  round  the  neck  between 
each  loop. 

To  support  the  breast,  a  figure-of-8  bandage  is 
applied,  one  turn  round  the  waist,  the  second  carried 
upward  under  the  breast  to  the  opposite  shoulder,  down- 
ward across  the  back,  under  the  axilla,  on  the  side  from 
which  the  bandage  started  to  the  starting-point,  and  again 


Fig.  82. — Crossed  bandage  of          Fig.  83. — Figure-of-8  bandage 
the  angle  of  the  jaw  (DaCosta).  of  the  breast  (DaCosta). 

round  the  waist.  The  turns  are  repeated  as  often  as 
necessary,  each  turn  covering  two-thirds  of  the  turn 
below  and  crossing  below  the  breast. 

The  two  breasts  may  be  bandaged  at  the  same  time. 
The  first  turn  having  passed  over  the  right  breast,  as 
already  described,  the  next  turn  is  taken  upward  under 
the  outer  margin  of  the  left  breast  and  under  the  left  axilla 
to  the  back,  across  the  back  over  the  right  shoulder,  and 
down  under  the  inner  margin  of  the  left  breast;  half  a 
turn  round  the  body  then  brings  the  bandage  back  again 
to  the  starting-point. 

Capeline  Bandage. — To  cover  the  round  ball  of  the  head 
neatly  requires  practice.  The  ends  of  two  bandages  1\ 
inches  wide  are  sewn  flatly  together,  or  one  bandage  10 


296 


BANDAGES   AND    SPLINTS 


yards  long  may  be  rolled  from  either  end,  forming  a 
double  roller  bandage.  Standing  in  front  of  the  patient, 
the  two  rollers  are  rolled  from  the  center  of  the  forehead 
to  the  back  of  the  occiput  and  crossed.  The  under 
roller  is  next  brought  directly  back  to  the  center  of  the 
forehead,  over  the  crown  of  the  head;  the  second  roller 
is  brought  round  the  head  over  the  temple,  passes  over 
the  first  roller  in  the  center  of  the  forehead,  fixing  it,  and 
is  continued  round  the  head  to  the  occiput.  The  first 
roller  is  doubled  back  over  the  crown  and  fixed  at  the 
occiput  by  the  second  roller  in  the  same  way.  These 
turns  are  then  repeated,  the  first  roller  going  obliquely 
alternately  to  the  right  and  left  of  the  first  point  covered, 
and  overlapping  two-thirds  of  the  turn  immediately 


Fig.  84. — Recurrent  bandage 
of  the  head  (DaCosta) . 


Fig.  85. — Velpeau's  bandage 
(DaCosta). 


below,  the  second  roller  fixing  the  first  at  the  occiput  and 
forehead.  If  the  turns  of  the  first  bandage  are  neatly 
made,  they  are  shown  to  cross  in  front  of  the  crown,  and 
behind  over  the  occiput. 

Velpeau's  bandage,  for  fractured  clavicle  or  collar-bone, 
is  one  in  fairly  frequent  use,  which  a  nurse  should  know 
how  to  apply. 

A  pad  or  folded  towel  is  placed  in  the  axilla  of  the 
affected  side,  and  the  hand  brought  up  and  made  to  grasp 
the  sound  shoulder;  the  point  of  the  elbow  should  be  in 
front  of  the  sternum  ;the  site  of  fracture  is  protected  by  a 
pad;  the  chest  is  well  powdered,  and  covered  with  a  towel 
on  which  the  arm  rests.  The  bandage  is  applied  by  a 


BANDAGES 


297 


series  of  double  turns,  after  first  fixing  by  two  turns 
round  the  chest.  The  bandage  starts  from  the  axilla 
on  the  uninjured  side,  is  carried  across  the  back  over  the 
injured  shoulder,  down  over  the  middle  of  the  upper  arm 
and  behind  the  elbow,  across  the  chest,  to  the  starting- 
point;  the  second  turn  is  carried  straight  across  the  back 
round  the  chest,  over  the  flexed  arm,  and  so  back  to  the 
starting-point.  The  downward  turns  advance  from  the 
middle  of  the  arm  until  the  elbow-point  is  covered,  each 
turn  overlapping  two-thirds  of  the  turn  below;  the  straight 
turns  cover  the  elbow-point  first,  and  are  carried  as  high 
up  the  arm  as  is  necessary,  each  turn  also  overlapping 
half  of  the  turn  below. 

The  roller  bandage  is  used  in  making  the  T-bandage, 
the  four-tailed  bandage,  and  the  many-tailed  or  Scul- 
tetus  bandage. 

The  T-bandage  is  used  to  retain  perineal  dressings 
and  pads.  It  is  made  from  two  pieces  of  a  roller  bandage 


Fig.  86.— T-bandage. 


Fig.  87. — T-bandage  divided. 


4  inches  wide.  One  piece  1  yard  long  is  folded  and  stitched, 
forming  a  belt  2  inches  wide.  A  second  piece  is  cut,  2 
yards  long,  doubled  in  half,  and  stitched,  forming  a  strip 
a  yard  long  by  4  inches  wide.  The  wide  strip  is  sewn  to  the 
center  of  the  narrower,  forming  a  7,  of  which  the  arms 
are  fastened  round  the  waist,  while  the  tail  comes  from 
behind  over  the  perineum,  and  is  slipped  under  the  belt 
in  front  and  pinned.  Frequently  the  wide  strip  is  divided 
down  the  center  to  half  its  length.  The  two  tails  so 
formed  are  brought  up  between  the  legs  and  fastened  to  the 
belt  on  either  side  of  the  abdomen. 


298 


BANDAGES   AND   SPLINTS 


The  four-tailed  bandage  is  used  for  the  lower  jaw.  A 
length  one  yard  long  of  a  4-inch  roller  bandage  is  re- 
quired. Exactly  in  the  center  a  small  hole  is  cut.  From 
each  end  the  strip  is  torn  down  the  center  of  the  width, 
to  within  a  couple  of  inches  of  the  hole.  The  hole  is 
placed  over  the  point  of  the  chin;  the  strips  thus  placed 


Fig.  88. — Four-tailed  and  many- 
tailed  bandages  (Stoney). 


Fig.  89. — Four-tailed  bandage 
for  the  jaw  (Stoney). 


uppermost  are  then  tied  under  the  occiput  with  a  single 
knot  pulling  the  jaw  back;  the  lower  strips  are  brought 
from  under  the  chin  in  front  of  the  ears  and  tied  on  the 
crown  with  a  single  knot,  thus  pulling  the  jaw  upward; 
the  bandage  is  secured  by  tying  each  end  of  the  lower  strip 
to  one  of  the  upper  strips  in  a  bow-knot. 

The  many-tailed  or  Scultetus 
bandage  forms  an  elastic,  close- 
fitting  bandage  for  the  abdomen, 
and  is  commonly  used  after  ab- 
dominal operations.  Six  or  eight 
strips  of  bandage,  4  inches  wide 
and  a  yard  and  a  half  long,  are 
placed  one  above  the  other,  each 
overlapping  two-thirds  of  the  one 
below.  Three  rows  of  stitching, 
one  in  the  center  and  the  others 


Fig.  90.— Scultetua  band- 
age (Stoney). 


three  inches  to  either  side,  keep  the  strips  in  place,  or 

they  may  be  stitched  down  on  to  a  wide  piece  of  bandage. 

To  apply,  the  bandage  is  rolled  from  either  side  to  the 

center  and  slipped  below  the  patient's  back.     The  strips 


BANDAGES  299 

are  then  unrolled  and  brought,  alternately  right  and  left, 
obliquely  across  the  abdomen  and  tucked  firmly  in  on  the 
opposite  side,  each  strip  crossing  the  opposite  strip  in 
the  center.  The  bandage  is  usually  applied  from  above 
toward  the  pubes.  The  two  lower  strips  are  pinned  in 
front,  or  they  may  be  brought  upward  to  opposite  sides 
of  the  bandage  and  pinned  to  the  upper  margin.  In 
using  the  bed-pan  or  attending  to  the  back  these  two 
strips  can  be  unpinned  and  turned  back  without  displacing 
the  bandage.  A  T -strip  may  be  added  to  the  Scultetus; 


Fig.  91. — Many-tailed  bandage  for  the  abdomen  (Fowler). 

brought  over  the  perineum  and  pinned  in  front,  it  serves 
to  keep  the  bandage  from  slipping  upward. 

A  many-tailed  bandage  may  also  be  used  for  the  spine 
or  for  a  limb,  where  it  is  desirable  not  to  disturb  the  part 
by  lifting. 

Binders. — -For  support  or  in  order  to  retain  dressings, 
etc.,  on  abdomen,  chest,  or  spine,  a  binder  is  frequently 
more  practical  than  a  roller  bandage.  A  binder  may  be 
made  of  a  double  piece  of  stout  muslin,  flannel,  or  roller 
toweling;  it  should  be  about  12  to  18  inches  wide  and  long 
enough  to  go  easily  once  and  a  half  times  round  the 
body. 


300 


BANDAGES   AND   SPLINTS 


An  abdominal  binder  is  generally  used  in  obstetric 
cases  in  preference  to  a  Scultetus.  It  is  fastened  exactly 
in  front  with  safety-pins  set  closely  together.  The  lower 
margin  should  be  four  inches  below  the  trochanter,  the 
upper  margin  about  the  waist-line.  To  make  the  binder 
fit  closely  darts  are  made  at  the  waist-line  and  below  the 
hip  in  front,  with  closely  set  safety-pins.  The  binder 
should  fit  without  a  wrinkle  and  be  neat  in  appearance. 


Fig.  92. — Abdominal  binder  and  breast  binder  in  place  (Dickinson, 
from  a  photograph). 


Breast  Binder. — The  same  binder  may  be  used  for  the 
breasts,  either  to  supply  pressure  or  to  retain  dressings. 
The  bandage  is  pinned  in  front,  and  darts  pinned  as 
necessary  on  either  side  below  the  breasts  and  above. 
Straps  attached  to  the  binder  behind  are  brought  over  the 
shoulder  and  pinned  in  front  to  keep  the  binder  in  place. 

A  modification  of  this  bandage  is  made  by  cutting  the 
binder  with  arm-holes  and  shoulder-pieces.  The  shoulder- 
pieces  are  pinned  when  in  place,  and  the  darts  taken 
below  each  breast  with  either  bandage.  The  breasts 


BANDAGES 


301 


should  be  surrounded,  covered,  except  immediately  over 
the  nipples,  with  a  generous  layer  of  cotton,  and  the 
binder  kept  tightly  pinned.  There  should  be  no  pressure 
directly  on  the  nipples. 


... 

Fig.  93. — The  breast  binder  applied  (De  Lee). 

Y-shaped  Binder. — Some  obstetric  hospitals  use  what 
is  known  as  the  Y-shaped  breast  binder.  This  is  made 
of  two  hand-towels  folded  lengthwise  in  four.  One  of 
the  folded  towels  is  then  doubled  in  a  bias  fold  and  pinned 
with  closely  set  safety-pins  to  one  end  of  the  straight 
towel,  forming  the  Y.  When  applied 
the  tail  of  the  Y  is  carried  round  the 
back,  the  arms  of  the  Y  are  brought 
firmly  one  above  and  one  below  the 
breasts,  and  pinned  to  the  tail  on  the 
opposite  side.  The  breasts  must  be 
well  packed  with  cotton,  and  the  band- 
age applied  so  as  to  press  the  breasts 
from  above  and  below  between  the 
upper  and  under  arm  of  the  bandage. 
The  nipples  are  free  from  pressure. 
The  free  end  of  the  tail  may  be  pinned  across  the  chest, 
but  is  not  used  to  exert  pressure.  The  bandage  is  applied 
as  tightly  as  possible. 

The  handkerchief  or  triangular  bandage  is  more  used 


Fig.  94.— Y-band- 
age. 


302  BANDAGES  AND   SPLINTS 

in  emergency  work  than  in  hospital  nursing,  but  is  often 
useful  where  dressings,  etc.,  have  to  be  frequently  changed. 


Fig.  95. — The  H-bandage    (Boston  Lying-in   Hospital)   (American 
Text-Book  of  Obstetrics). 

A  piece  of  muslin  a  yard  square,  cut  across  or  folded 
diagonally,  makes  a  triangular  bandage  of  suitable  size. 


Fig.     96.— Hand-  Fig.        97.— Three-  Fig.   98.— Four-cor- 

kerchief  bandage  for  cornered  bandage  for  nered  bandage  for  arm 

perineum    and    hip  arm  (Stoney).  (Stoney). 
(Stoney). 

To  apply  to  the  head,  the  center  of  the  diagonal  margin 
is  laid  across  the  forehead,  the  point  of  the  handkerchief 


BANDAGES 


303 


hanging  behind.  The  two  ends  are  crossed  above  the 
tail  below  the  occiput,  brought  up  on  either  side  of  the 
head,  and  tied  over  the  forehead. 
The  point  is  brought  up  from  behind 
and  pinned  on  the  top  of  the  head. 

The  handkerchief  may  also  be  used 
for  the  foot  or  the  hand.  The  mem- 
ber is  laid  in  the  center  of  the  band- 
age, the  longer  margin  or  base  of  the 
triangle  round  the  wrist  or  ankle. 
The  point  is  brought  from  behind 
over  the  front  of  the  foot  or  the  back 
of  the  hand,  and  the  two  ends  crossed 
over  the  point,  passed  round  behind, 
and  brought  up  and  tied  in  front  in  a  surgical  knot  (see 
below).  The  point  is  folded  back  and  pinned  below  the 
knot.  The  triangular  bandage  is  easily  folded  as  small 
as  required. 

A  stump  may  be  bandaged  in  the  same  way.     In  apply- 
ing a  handkerchief  to  the  shoulder  or  hip  the  lower  margin 


Fig.  99.— Triangu- 
lar bandage  of  the 
head. 


Fig.  100. — Various  forms  of  handkerchief  bandages:  a,  For  the 
chest;  b,  for  the  shoulder,  hand,  and  arms;  c,  double  bandage  to 
prevent  motion  of  the  arm  (Stoney). 

or  base  is  passed  round  the  upper  arm  or  the  thigh,  and 
tied  in  front,  the  point  of  the  handkerchief  lying  upper- 
most and  in  front.  A  strip  of  roller  bandage  or  a  second 
handkerchief  folded  into  a  band  is  tied  respectively  round 
the  waist  or  round  the  neck  and  opposite  axilla.  The 


304  BANDAGES   AND   SPLINTS 

point  is  slipped  beneath  the  band  so  formed  and  pinned 
over. 

The  handkerchief  is  in  common  use  as  a  sling  for  the 
support  of  the  arm.  Laying  the  forearm  in  the  center, 
the  hand  at  the  lower  margin  or  base,  and  the  point  over 
the  elbow,  the  two  ends  are  tied  behind  the  neck,  the 
end  of  the  half  lying  outside  the  arm  passing  round  the 
opposite  side  of  the  neck.  The  point  is  brought  over  the 
elbow  and  pinned  in  front.  Where  the  wrist  alone  is 
supported,  the  handkerchief  is  folded  into  a  strip  and 
tied  behind  the  neck  in  the  same  way. 

A  stiff  bandage  is  frequently  necessary  to  insure  im- 
mobility, as  in  the  treatment  of  fractures,  dislocations,  or 
diseased  joints,  or  following  operations  for  deformities. 

PLASTER-OF-PARIS  BANDAGE 

Plaster-of-Paris  is  the  stiffening  most  commonly  used. 
Plaster  bandages  are  made  of  crinolin,  muslin,  or  a  Ic/ose- 
meshed  coarse  muslin.  If  crinolin  is  used,  the  plaster 
is  retained  better  if  the  pieces  are  washed  and  mangled 
before  the  bandages  are  torn.  The  bandages  are  cut 
usually  5  yards  long  and  rolled.  Well-dried  plaster-of- 
Paris  is  then  rubbed  thoroughly  into  the  bandage,  unrolling 
a  few  inches  at  a  time,  and  rolling  again,  but  not  too 
tightly.  A  bandage  roller  fitted  over  a  shallow  box  filled 
with  the  plaster  is  a  practical  apparatus  for  rolling  the 
bandage  quickly.  Each  bandage  is  wrapped  separately 
in  oiled  paper  to  exclude  the  air,  from  which  plaster-of- 
Paris  readily  absorbs  moisture,  which  ruins  the  bandage; 
as  a  further  precaution,  the  bandages  should  be  stored  in 
an  air-tight  tin  box  and  kept  in  a  warm,  dry  place. 

Technic. — Before  applying  a  plaster  bandage,  the  limb 
is  well  washed,  dried,  and  powdered,  and  protected  by  a 
preliminary  bandage  of  flanelette,  of  shaker  flannel,  or 
by  strips  of  raw  sheet  cotton,  applied  like  a  bandage. 

In  applying,  the  bandage  is  dipped  into  water,  hot  water 
causing  the  plaster  to  harden  or  set  more  quickly  than 
cold.  Salt,  \  ounce  to  the  quart,  added  to  the  water  also 
hastens  the  process  of  setting.  The  water  should  be  suf- 
ficiently deep  to  cover  the  bandage  placed  upright,  in 


PLASTER-OF-PARIS   BANDAGE  305 

which  position  the  water  percolates  most  thoroughly. 
It  must  be  applied  directly  it  is  saturated  and  before  the 
plaster  has  time  to  set.  The  bandage  is  ready  for  use,  and 
should  be  taken  out  of  the  water  directly  no  more  air- 
bubbles  are  seen  to  escape.  It  is  then  gently  squeezed 
and  applied  evenly  in  a  simple  spiral.  A  cream  of  the 
plaster,  made  of  equal  parts  of  water  and  plaster,  is  rubbed 
evenly  over  the  applied  bandage  to  improve  the  appearance. 

The  plaster  must  be  left  exposed  until  quite  dry,  and 
care  taken  that  the  required  position  is  retained  until  the 
bandage  is  hard.  Before  it  is  too  hard,  a  line  is  cut  with 
a  sharp  knife  down  the  center  of  the  bandage,  in  order 
that  the  cast  may  be  removed  when  necessary.  To 
protect  the  patient  a  narrow,  flat  strip  of  metal  is  usually 
placed  under  the  first  turn  of  the  plaster  bandage  and  the 
cutting  is  made  over  it.  If  the  plaster  has  not  been  cut 
before  hardening,  the  line  of  incision  may  be  softened  with 
vinegar  or  with  dilute  hydrochloric  acid.  A  vegetable 
knife  makes  a  good  cutting  instrument  for  the  purpose, 
or  a  special  pair  of  shears,  known  as  plaster  shears,  may 
be  used.  This  consists  of  a  cutting  blade  which  cuts 
downward  onto  a  narrow  metal  plane,  the  plane  being 
slipped  under  the  turns  of  the  bandage. 

Opening  in  Bandage. — It  may  be  necessary  to  make  an 
opening  in  the  plaster  cast  over  a  wound,  in  order  to 
change  a  dressing  without  removing  the  splint.  In  the 
case  of  small  openings,  a  thumb  tack  may  be  inserted  in 
the  first  turn  of  the  plaster  bandage,  the  point  turned  out- 
ward exactly  in  the  center  of  the  proposed  opening. 
When  the  bandage  is  completed,  the  sharp  point  can  be 
felt,  and  the  required  circle  cut  round  it. 

For  large  dressings  involving,  for  example,  an  entire 
joint,  an  interruption  is  usually  made.  The  bandage  is 
applied  in  two  parts,  above  and  below  the  dressing.  Strips 
of  metal,  usually  covered  in  rubber,  are  used  to  connect 
the  two  parts,  and  are  fixed  in  place  by  the  turns  of  the 
bandages.  The  metal  strips  are  arched  so  as  to  give  plenty 
of  room  for  the  dressings. 

Bony  prominences  should  be  padded  with  cotton  before 
applying  a  stiff  bandage.  After  applying  such  a  bandage 

20 


306  BANDAGES   AND   SPLINTS 

to  an  extremity  the  fingers  and  toes,  which  are  purposely 
left  uncovered,  should  be  examined  from  time  to  time. 
If  they  appear  blue  or  cold,  or  the  tissues  immediately 
below  the  bandage  become  swollen  and  edematous,  the 
bandage  is  too  tight  and  must  be  cut. 

To  insure  greater  rigidity,  the  plaster  bandage  may  be 
braced  by  thin  strips  of  metal,  wood,  or  card-board,  held 
in  place  by  the  turns  of  the  bandage. 


Fig.  101. — Interrupted  plaster-of -Paris  case  (DaCosta). 

Sayre's  Spinal  Jacket. — In  applying  a  plaster  cast  to 
the  spine  in  the  treatment  of  spinal  curvature  (known  as 
Sayre's  jacket),  it  is  necessary  that  the  spine  should  be 
extended  during  the  process.  To  do  this  an  apparatus 
usually  known  as  the  gallows  is  used  (Fig.  102). 

This  consists  of  a  tripod,  from  which  hangs,  by  a  pulley, 
a  wooden  cross-bar;  from  the  cross-bar  are  suspended  a 
padded  leather  collar  shaped  to  support  the  chin  and  occi- 
put, and  a  pair  of  padded  loops  through  which  the  arms 
are  thrust.  The  patient  supported  thus,  traction  is  made 
over  the  pulley  until  the  patient  is  raised  on  his  toes. 
A  woven  sleeveless  jersey  is  worn  next  the  skin:  the  bony 
prominences  and,  in  a  female  patient,  the  breasts,  are 
well  padded,  and  a  folded  towel  is  placed  over  the  stomach, 
forming  a  "  dinner-pad,"  which  is  removed  after  the 
bandages  are  set.  The  bandages  are  usually  6  inches 
wide  for  an  adult  and  4  for  a  child.  They  are  applied 
evenly  round  the  trunk,  from  below  the  crest  of  the  ilium 
to  the  axilla.  Before  drying  an  incision  is  made  down  the 
front,  so  that  the  cast  can  be  readily  removed.  The 
opening  may  be  neatly  bound  with  strips  of  thin  leather, 
to  which  hooks  are  attached,  so  that  the  jacket  may  be 


PLASTER-OF-PARIS   BANDAGE 


307 


laced.      Otherwise  the  jacket  is  kept  adjusted  by  a  few 
turns  of  a  muslin  bandage. 

The  object  of  the  Sayre  jacket  is,  by  extending  the 
spine,  to  keep  the  inflamed  surfaces  of  the  vertebrae  a&art, 
and  to  throw  the  weight  of  the  body  on  to  the  pelvic  bones 
instead  of  the  spinal  column.  Where  complete  extension 
is  necessary,  the  jacket  is  reinforced  by  an  apparatus  known 
as  Sayre's  jury-mast.  This  consists  of  a  padded  collar 
supporting  the  chin  and  occiput,  fastened  by  straps  to 
a  fixed  steel  support  which  comes  from  the  back  and  is 


Fig.  102. — Applying  a  plaster-of- 
Paris  jacket  (Sayre). 


Fig.  103.— Plaster-of-Paris 
jacket  and  jury-mast  applied 

(Sayre). 


arched  above  the  head.  The  steel  is  attached  to  a  brace 
worn  round  the  body,  or  if  the  plaster  jacket  is  also  used, 
it  is  kept  in  place  by  the  turns  of  the  plaster  bandages. 

A  starch  bandage  is  less  heavy  than  a  plaster  bandage, 
but,  as  it  is  also  less  rigid,  it  is  not  so  frequently  used. 

The  part  is  first  protected  by  a  single  bandage  of  flannel- 
ette or  shaker  flannel.  A  gauze  bandage  loosely  rolled 
is  then  dipped  into  a  basin  of  laundry  starch  prepared  in 
the  usual  way,  gently  squeezed  free  of  superfluous  moisture, 
and  applied  evenly  in  figure-of-8  turns.  As  many  layers  as 


308  BANDAGES   AND    SPLINTS 

are  necessary  are  applied  over  the  first.  A  starch  bandage 
takes  comparatively  long  to  dry.  As  it  is  soft  until  quite 
dry,  sand-bags  must  be  placed  to  insure  the  position  being 
retajned,  and  no  movement  permitted. 

Water  Glass. — A  solution  of  silicate  of  sodium  (or  water 
glass)  is  also  used  to  form  a  stiff  bandage,  especially  for 
the  extremities.  It  is  also  light,  but  more  rigid,  than  a 
starch  bandage.  A  flannelette  or  shaker  flannel  bandage 
is  first  applied,  and  over  it  a  gauze  bandage,  in  figure-of-8 
turns.  The  silicate  is  then  painted  over  the  bandage 
with  a  painter's  brush.  A  few  minutes  are  allowed  for 
partial  drying,  and  the  next  bandage  applied  in  the  same 
way.  Four  to  six  bandages  are  usually  necessary.  The 
silicon  bandage  also  takes  long  to  set — usually  not  less 
than  twenty-four  hours.  The  drying  may  be  hastened 
by  hot-water  cans. 

Wax  bandages  are  not  much  used  at  the  present  day. 
They  form  light,  rigid  bandages,  especially  suitable  for 
young  children,  and  have  the  advantage  that  they  become 
less  readily  impregnated  with  urine  or  fecal  matter  than 
plaster-of-Paris.  They  are  used  chiefly  for  the  extremi- 
ties, to  retain  splints  in  the  treatment  of  fractures  and  dis- 
eases of  the  joints.  Paraffin  wax  is  used,  heated  to  melt- 
ing-point. Loosely  rolled  muslin  (not  gauze)  bandages 
are  soaked  for  a  few  moments  in  the  wax,  and  applied 
quickly  before  the  wax  sets.  Absorbent  cotton  is  also 
soaked  in  the  wax  and  used  for  the  padding.  Each 
bandage  should  not  be  more  than  3  yards  long,  other- 
wise the  wax  will  have  cooled  before  the  entire  bandage  is 
applied.  The  limb  is  first  protected  by  a  light  flannelette 
bandage. 

SPLINTS 

A  splint  is  an  appliance  for  securing  local  immobility 
in  the  treatment  of  accidents  or  disease  of  the  bones  and 
joints,  and  for  the  correction  of  deformities  of  the  extremi- 
ties. Ordinarily,  splints  are  made  of  wood  or  of  metal; 
hard  rubber,  stiff  felt,  and  card-board  are  materials 
also  frequently  used. 

Padding    Splints. — Metal    splints    which    are    usually 


SPLINTS  309 

in  special  shapes,  are  covered,  when  padding  is  necessary, 
with  leather  or  with  chamois  leather. 

Wooden  splints  require  to  be  thickly  padded  with  tow 
or  non-absorbent  cotton.  To  make  the  pad,  a  strip  of 
unbleached  muslin  or  old  linen  is  cut  four  times  the  width 
of  the  splint.  A  smooth  layer  of  unbleached  raw  cotton, 
and  sufficient  tow  pulled  evenly  to  form  a  thick  pad,  are 
laid  on  the  strip,  and  the  edges  are  folded  over  and  tacked 
together.  The  pad  is  then  laid  on  the  splint  (the  sewn 
surface  next  the  splint)  and  sewn  in  place  by  a  herring- 
bone stitch  in  stout  linen  thread  across  the  back  of  the 
splint.  The  ends  at  the  top  and  bottom  are  turned  over 
and  neatly  sewn. 

In  an  emergency  the  padding  may  be  quickly  bandaged 
to  the  splint,  but  the  better  way  is  the  more  comfortable, 
as  it  less  readily  becomes  wrinkled  or  lumpy. 

Besides  the  padding,  small  pillows,  a  few  inches  square, 
made  of  muslin  stuffed  with  tow  and  non-absorbent  cotton, 
must  be  used  to  protect  bony  prominences,  such  as  at  the 
ankle,  the  knee,  or  the  elbow.  In  applying  a  splint  to  the 
leg  a  small  pad  should  be  placed  above  the  heel,  sufficiently 
thick  to  prevent  the  heel  resting  on  the  splint. 

Pressure-sore. — Undue  pressure  from  a  splint  may 
produce  a  pressure-sore,  which,  in  origin  and  appearance, 
is  similar  to  a  bed-sore.  The  preliminary  symptoms  of 
heat,  aching,  or  pain  must  never  be  disregarded.  On 
the  first  indication  the  splint  should  be  removed,  the  part 
rubbed  with  alcohol,  and  protected  from  further  pressure 
by  careful  padding.  When  a  pressure-sore  has  once 
formed,  it  is  treated  in  the  same  way  as  a  bed-sore. 

Preparation.— Before  applying  a  splint  the  limb  should, 
if  practicable,  be  well  washed  and  thoroughly  dried  and 
powdered.  If  strapping  is  to  be  used,  it  should  also  be 
shaved.  If  abrasions  are  present,  they  are  usually  dressed 
with  powdered  zinc  or  with  zinc  ointment,  and  covered 
with  gauze.  A  blister  is  pricked  with  a  sterile  needle,  the 
fluid  gently  pressed  out  without  removing  the  cuticle,  and 
covered  with  absorbent  cotton. 

Splints  are  kept  in  place  usually  with  bandages  of  stout 
muslin,  and  two  or  three  strips  of  adhesive  strapping. 


310  BANDAGES   AND    SPLINTS 

In  many  cases  more  than  one  splint  is  used  for  the  limb, 
as,  for  example,  in  back  and  side  splints  (see  below),  or 
in  putting  up  a  fracture  of  the  forearm.  In  such  cases,  to 
avoid  a  second  bandage,  the  outer  splints  are  kept  in 
place  by  tapes,  or  more  neatly  by  straps  of  narrow  webbing 
furnished  with  small  buckles. 

Rules. — A  few  general  rules  in  applying  splints  are 
applicable  in  the  majority  of  cases,  and  should  be  borne 
in  mind: 

1.  The  joint  above  and  below  the  seat  of  injury  should 
be  at  rest. 

2.  The  fingers  and  toes  should  be  left  exposed;  their 
color  and  warmth  are  indications  of  the  condition  of  the 
circulation;  if  they  turn  blue  or  cold  the  bandages  should 
be  removed. 

3.  A  bandage  should  not  be  applied  under  a  splint  when 
it  can  be  avoided;  if  one  is  essential,  it  must  be  put  on 
loosely  and  lightly. 

4.  In  fracture  cases  the  bandage  is  not  usually  applied 
directly  over  the  seat  of  fracture. 

Immobilizing. — Unless  the  splint  is  very  heavy,  some 
further  means  are  generally  necessary  to  keep  a  limb  at 
absolute  rest.  Sand-bags,  one  on  either  side,  may  be 
used,  or  one  sand-bag  to  which  the  splint  is  tied;  in  the 
case  of  a  lower  extremity,  the  leg  may  be  swung  in  a 
cradle  (see  below).  An  arm  is  usually  most  conveniently 
tied  on  to  a  pillow. 

A  splint  must  be  constantly  examined  to  see  that  the 
desired  position  is  exactly  maintained. 

The  splints  in  common  use  are  the  straight  splint,  the 
back  splint,  and  the  internal  and  anterior  angular  splints. 
They  are  usually  made  of  pine  or  oak. 

The  straight  splint  is  cut  to  a  convenient  length  from  a 
board  \  to  i  inch  thick,  and  from  3  to  6  inches  wide.  It 
is  used  for  a  variety  of  purposes.  In  short  lengths  it  is 
a  convenient  method  for  keeping  a  single  joint  at  rest,  as 
the  elbow,  the  wrist,  the  knee,  for  which  purpose  it  is 
generally  applied  to  the  flexor  surface.  A  couple  of 
straight  splints  applied  to  the  inner  and  outer  surface  of 
the  forearm  is  a  common  method  of  putting  up  fractures 


SPLINTS  311 

of  the  forearm.  The  inner  splint  is  bandaged  to  the  arm, 
and  the  outer  splint  kept  in  place  by  straps  and  buckles. 
The  splints  extend  from  beyond  the  elbow  to  the  roots  of 
the  fingers. 

In  conditions  where  complete  immobilization  of  the 
whole  lower  extremity  is  necessary,  as  in  fractures  of  the 
femur,  a  straight  splint  may  be  applied  outside  the  limb, 
extending  from  the  axilla  to  beyond  the  foot.  It  is  gen- 
erally known  as  a  long  splint.  The  splint  is  kept  in  place 
with  a  wide  rib  roller  round  the  body,  and  a  figure-of-8 
bandage  from  the  foot  to  immediately  below  the  seat  of 
of  injury  (or  disease).  Frequently  the  long  splint  is  used 
in  connection  with  a  Buck's  extension  (see  below).  In 
this  case  the  limb  is  not  bandaged  to  the  splint,  but  kept 
in  place  by  three  ties  applied  one  above  the  knee,  one 
below  the  knee,  and  one  above  the  ankle.  A  straight  splint 


Fig.  104. — Straight  splints  applied  to  a  fractured  arm  (Stoney). 

is  also  used  in  injuries  to  the  upper  extremity,  where  the 
arm  is  fully  extended. 

The  back  splint  consists  of  a  straight  splint  to  which  a 
foot-piece  is  attached  at  right  angles.  It  is  used  in  the 
treatment  of  injuries  and  disease  of  the  leg  or  foot.  In 
fractures  of  the  leg  the  splint  must  be  sufficiently  long  to 
extend  beyond  the  knee  and  keep  the  joint  at  rest.  In 
applying,  a  couple  of  strips  of  adhesive  plaster  are  generally 
used  under  the  bandage,  one  below  the  knee  and  one  above 
the  ankle.  In  order  to  minimize  pressure  on  the  heel  the 
splint  usually  has  an  opening  cut  in  the  back  piece,  at  the 
point  where  the  heel  rests,  and  a  small  pad  is  placed  im- 
mediately above  the  heel.  The  heel  is  left  unbandaged, 
in  order  that  the  heel  pad  can  be  readily  adjusted,  if 
necessary. 

Where  immobility  is  an  essential  part  of  the  treatment, 
as  in  a  fracture,  a  pair  of  straight  splints  are  also  used, 


312 


BANDAGES   AND    SPLINTS 


one  on  either  side  of  the  back  splint,  and  commonly  known 
as  side  splints.     The  leg  is  bandaged  to  the  back  splint, 
and  the  side  splints  are  kept  in  place  by  straps  and  buckles. 
The  side   splints  can 
be  removed  and  reap- 
plied  without  disturb- 
ing the  limb. 


Fig.  105.— Box-splint 
(DaCosta). 


Fig.   106. — Internal  angular  splint 
(DaCosta). 


Box  Splint. — This  is  a  modification  of  the  above,  and 
consists  of  a  back  splint,  to  which  the  side  splints  are 

attached  by  hinges  (Fig.  105). 
A  thick  pillow  is  used  as  a 
pad,  and  the  whole  is  kept  in 
place  by  webbing  straps. 

The  angular  splint  is  used 
in  the  treatment  of  the  upper 
extremity,  where  it  is  desir- 
able to  keep  the  elbow  flexed 
and  at  complete  rest. 

The  internal  angular  splint 
(Figs.  106,  107)  consists  of  a 
couple  of  straight  splints 
joined  at  right  angles,  one  arm 
considerably  shorter  than  the 
other.  It  is  applied  to  the 
internal  surface  of  the  upper 
extremity,  held  with  the  elbow 

flexed;  the  short  arm  reaches  from  the  axilla  to  the  elbow, 
the  long  arm  from  the  elbow  to  the  roots  of  the  fingers  or 
beyond  as  desired.  The  internal  angular  splint  is  used  in 
fractures  and  injuries  to  the  upper  arm. 


Fig.  107. — Internal  angular 
splint  in  fracture  of  the  shaft 
of  the  humerua  (DaCosta). 


SPLINTS 


313 


The  anterior  angular  splint  (Figs.  108,  109)  is  made  of 
two  pieces  of  wood,  deeply  grooved,  and  joined  at  right 
angles,  and  is  applied  to  the  anterior  surface  of  the  flexed 
arm;  that  is  to  say,  the  bend  of  the  arm  fits  into  the  groove. 
In  this  position  the  point  of  the  elbow  is  outside  the  splint. 
It  is  used  in  the  treatment  of  injuries  accompanied  by 
dislocation  of  the  elbow  or  injuries  at  or  near  the  elbow. 

Splints  for  the  upper  ex- 
tremity should  be  as  light  as 
is  consistent  with  strength; 
those  for  the  lower  ex- 
tremity are  more  solid;  if 
of  wood,  the  latter  should 
be  at  least  \  inch  thick. 

Numerous  special  splints 
are    in    use,    both    in    con-    Fig  108._Anterior  angular  splint 
nection   with    general    and  (DaCosta). 

with    orthopedic     surgery, 

especially  devised  for  the  maintenance  of  special  positions. 
Usually  they  are  made  in  sheet  iron,  tin,  or  aluminum,  and 
are  padded  with  leather,  chamois  leather,  or  outing 


Fig.  109.- 


-Anterior  angular  splint  for  fractures  near  the  elbow-joint 
(DaCosta). 


flannel.  To  fulfil  their  function  they  must  fit  the  part  and 
be  carefully  adjusted;  usually  they  are  kept  in  place  by 
straps  and  buckles.  Such  splints  are  frequently  called  by 
the  name  of  the  surgeon  who  originally  employed  them. 


314  BANDAGES   AND   SPLINTS 

Frequently,  in  hospital  work,  from  motives  of  economy, 
plaster-of-Paris  bandages  take  the  place  of  special  splints 
in  orthopedic  work. 

Bond's  splint  (Figs.  110,  111)  is  used  in  fracture  of  the 
lower  end  of  the  radius  (Colics'  fracture,  p.  636).  This  is 
a  flat  light  splint,  made  of  wood,  the  sides  curved  to  the 
shape  of  the  forearm  and  fitted  with  leather  edges  about 


Fig.  110.— Bond's  splint  (DaCosta). 

an  inch  high.  Where  the  palm  rests  is  a  rounded  block 
of  wood  forming  a  comfortable  support.  The  splint  is 
applied  to  the  inner  surface  and  extends  from  the  elbow 
to  the  roots  of  the  fingers.  The  fingers  are  flexed  over 
the  rounded  block.  A  light  straight  splint  is  usually  ap- 
plied to  the  outer  surface  of  the  forearm. 


Fig.  111. — Bond's  splint  in  Colles'  fracture  (DaCosta). 


Levis  Splint. — This  is  somewhat  similar  to  the  Bond, 
and  is  also  used  in  the  treatment  of  Colles'  fracture.  It 
is  made  of  perforated  metal  and  grooved  to  fit  closely  to 
the  under  surface  of  the  arm.  A  molded  curve  supports 
the  palm  and  the  ball  of  the  thumb,  in  the  same  way  as  the 
wooden  block  of  the  Bond  splint. 


SPLINTS 


315 


Thomas'  hip  splint  (Fig.  112)  or  brace  consists  of  three 
bands  or  girdles  of  metal  on  a  narrow  iron  splint  extending 
from  the  shoulder  to  the  middle  of  the  leg.  One  band  en- 
circles the  body  under  the  arm;  another,  the  middle  of  the 
thigh,  and  the  third,  the  calf  of  the  leg.  The  bands  are 
brought  together  with  straps  and  buckles,  and  the  splint 
kept  in  position  by  a  brace  over  the  shoulder.  The  limb 
is  bandaged  to  the  splint  from  the  lower  support  to  the 
hip.  It  is  used  in  the  treatment  of  the  chronic  stage  of 


Fig.  112. — Thomas'  posterior 
splint. 


Fig.  113. — Thomas'  knee- 
splint. 


hip  disease,  where  the  patient  can  get  about  with  crutches. 
To  keep  the  affected  limb  entirely  off  the  ground,  a  thick 
sole  or  an  iron  patten  is  worn  on  the  foot  of  the  sound  limb. 
Thomas'  knee  splint  (Fig.  113)  or  brace  is  made  of  two 
steels  connected  at  the  upper  end  with  a  padded  metal  ring, 
and  ending  at  the  lower  end  in  a  steel  patten.  A  piece  of 
leather  or  stout  muslin  is  sewn  to  either  steel  to  form  a  ham- 
mock-like support  for  the  limb,  extending  several  inches 
above  the  knee,  and  as  far  below  as  the  ankle.  The  limb 
is  passed  through  the  padded  ring,  which  fits  closely  round 


316  BANDAGES   AND   SPLINTS 

the  hip  under  the  perineum,  and  supports  the  pelvic  bones 
on  the  affected  side.  A  brace  over  the  shoulder  keeps  the 
splint  in  place.  The  leg  is  bandaged  into  the  splint  from 
the  ankle  to  several  inches  above  the  knee.  In  standing, 
the  weight  of  the  body  is  carried  by  the  splint  from  the 
pelvic  bones  to  the  patten,  thus  keeping  all  weight  from 
the  knee.  A  thick  sole  or  patten  is  worn  on  the  sound 
foot.  The  splint  is  used  chiefly  in  chronic  tubercular 
affections  of  the  knee-joint. 

Dupuytren's  splint  (Fig  114)  is  by  many  surgeons  pre- 
ferred in  the  treatment  of  a  special  fracture  of  the  lower  end 
of  the  fibula,  known  as  Pott's  fracture  (p.  636),  of  which 
a  characteristic  symptom  is  the  dislocation  outward  of  the 
foot  (eversion).  The  splint  consists  of  a  short,  thick, 
wide  board,  with  notches  for  the  attachment  of  a  bandage 
or  strapping  at  the  lower  end;  when  applied,  it  extends  from 
the  knee  to  several  inches  below  the  foot.  A  very  thick 


Fig.  114. — Dupuytren's  splint  in  Pott's  fracture  (DaCosta). 

pad  covers  the  upper  part  of  the  splint,  ending  where  the 
internal  malleolus  (or  ankle  bone)  would  rest.  Below 
this,  the  padding  is  just  sufficient  to  avoid  pressure — 
usually  merely  a  few  thicknesses  of  a  flannel  bandage. 

The  splint  is  applied  to  the  inner  side  of  the  leg,  the 
ankle  placed  in  position  over  the  thick  pad,  and  held  by 
a  muslin  bandage  applied  in  a  figure-of-8  round  the  ankle 
and  foot,  and  each  turn  kept  from  slipping  by  being 
passed  round  the  notches.  A  second  bandage  is  applied 
from  above  the  fracture  to  the  knee.  The  object  of  the 
position  is  to  correct  the  eversion  of  the  foot.  The  patient 
lies  on  the  side,  with  the  knee  flexed,  the  splint  resting  on 
the  mattress  and  kept  immovable  by  sand-bags.  The 
position  is  usually  found  very  fatiguing. 

Hodgen's  splint  is  sometimes  used,  in  combination  with  an 
extension,  in  the  treatment  of  fracture  of  the  upper  third 
of  the  femur.  It  consists  of  two  parallel  pieces  of  thick 
wire,  across  which  strips  of  webbing  are  sewn  at  intervals 


SPLINTS' 


117 


to  form  a  sling.  Cross-pieces  of  wire  at  either  end,  and 
a  third  about  the  middle,  keep  the  splint  in  shape.  The 
splint,  when  applied,  reaches  from  above  the  fracture  to 
below  the  foot,  the  whole  limb  resting  on  the  webbing 
strips  as  in  a  shallow  trough.  At  the  knee  the  splint  is 
slightly  bent,  so  that  when  resting  on  the  splints  the 


Fig.  115. — Double  inclined  plane  (DaCosta). 

thigh  is  flexed  and  the  leg  is  extended.  A  Buck's  extension 
(see  below)  is  applied  from  the  knee  and  fastened  to  the 
lower  cross-bar.  Cords  and  pulleys  are  also  attached  to 
the  sides  of  the  splint,  one  pair  below  the  fracture  and  the 
other  about  the  ankle,  by  means  of  which  the  whole  limb 
is  suspended  to  an  upright  support  at  the  bottom  of  the 
bed. 


Fig.  116. — Fracture  of  the  femur  in  the  upper  third  with  extension 
upon  a  double  inclined  plane  (Agnew). 

The  Inclined  Plane. — This  is  used  in  fracture  of  the 
patella  when  it  is  necessary  to  keep  the  knee  immovable, 
with  the  leg  extended,  and  at  the  same  time  to  relax  the 
muscles  of  the  thigh.  It  consists  of  a  long  back  splint 
attached  by  a  hinge  at  the  upper  end  to  a  frame  which  rests 
on  the  bed;  the  frame  is  provided  with  grooves  into  which 
n  rest  attached  to  the  under  surface  of  the  splint  may  fit, 
thus  elevating  the  foot  to  the  degree  necessary. 


318 


BANDAGES   AND   SPLINTS 


The  position  described  under  Hodgen's  splint  may  also 
be  attained  by  the  double  inclined  plane.     It  is  made  like 
the  simple  inclined  plane,  with  the  addition  that  the  pos- 
terior splint  is  made  in  two  parts,  fitted  together  by  a 
hinge,  so  that  the  knee  can  be  bent. 
It   is  also   frequently   used,   with    or 
without  the  extension,   in  the  treat- 
ment of  fractures  of  the  femur,  es- 
pecially of  the  upper  and  lower  thirds. 
(Fractures   of  the  middle    third    are 
usually  treated  with  extension,  and  the 
limb  kept  straight  by  sand-bags  or  the 
application  of  a  straight  side  splint.) 

Gooch's  coaptation  splinting  consists 
of  a  sheet  of  waxed  canvas  to  which 
are  attached  long  parallel  straps  of 
thin  pine  wood,  about  \  inch  wide. 
They  may  be  cut  to  any  size,  and 
make  a  serviceable  application  where 
a  light  rigid  splint,  with  some  lateral 
molding,  is  desired. 

Poroplastic  is  the  name  given  to  a 
felt  saturated  with  a  preparation  of 
rubber  which  melts  on  exposure  to 
heat;  splints  of  this  preparation  are 
used  where  the  deformity  requires  the  splint  to  be  closely 
molded  to  the  limb.  A  piece  of  the  prepared  felt  is 
soaked  until  soft  in  hot  water,  and  then  molded  on  the 
limb  to  the  required  shape,  which,  when  dry,  it  retains. 

EXTENSION 

In  connection  with  chronic  joint  disease,  fractures,  or 
dislocations,  an  appliance  known  as  an  extension  is  fre- 
quently used.  Its  purpose  is,  by  the  employment  of 
continuous  traction,  to  keep  inflamed  surfaces  apart  and 
at  rest. 

Buck's  extension  apparatus  consists  of  a  stirrup,  a  pulley 
and  its  attachments,  two  strips  of  adhesive  strapping,  a 
length  of  stout  cord,  and  weights.  Blocks  to  raise  the 
bottom  of  the  bed  are  also  required. 


Fig.  117.— Gooch's 
coaptation  splinting 
(Scudder). 


EXTENSION 


319 


The  stirrup  is  made  of  a  piece  of  hard  wood  about  4 
inches  long  by  3  wide,  with  a  hole  in  the  middle.  A  piece 
of  webbing  about  9  inches  long,  to  either  end  of  which 
small  buckles  are  sewn,  is  attached  (either  by  tacks  or 
adhesive  strapping)  to  the  under  surface  of  the  piece  of 
wood,  and  forms  the  sides  of  the  stirrup;  the  cord  is 


Fig.  118. — Adhesive  plaster  applied  to  make  extension  (DaCosta). 

passed  through  the  hole  and  knotted  on  the  upper  surface 
of  the  stirrups.  The  pulley  is  attached  to  the  bed-rail, 
the  cord  carried  over  the  pulley,  and  the  weights  attached 
to  the  cord.  Iron  weights,  bags  of  shot,  or  toy  buckets 
filled  with  shot  or  pebbles  may  be  used,  but  should  always 
be  clearly  marked,  so  that  the  weight  carried  can  be  seen 
at  a  glance. 


Fig.   119. — Extension  apparatus.     A  bandage  is  applied  over  the 
strapping  (Da  Costa). 

The  most  common  use  of  the  extension  apparatus  is  in 
treatment  of  hip  disease  or  of  fractures  or  dislocation  of 
the  hip  or  femur.  In  these  cases  the  strips  of  adhesive 
plaster  2  or  3  inches  wide,  cut  sufficiently  long  to  reach 
from  the  fracture  or  seat  of  disease  to  3  or  4  inches  beyond 
the  foot,  are  applied  on  either  side  of  the  limb. 


320  BANDAGES    AND    SPLINTS 

Before  applying,  the  leg  should  be  washed,  and,  if 
necessary,  shaved.  The  strips  are  applied  to  the  inner  and 
the  outer  surface  of  the  limb,  stopping  just  above  the 
prominent  bones  of  the  ankle  (the  malleoli).  A  snip  is 
made  at  this  point  in  either  margin,  and  the  strip  of  plaster 
folded  on  itself,  so  that  the  adhesive  surface  is  covered. 
The  strips  are  kept  in  place  by  two  or  three  narrow  strips 
of  plaster  applied  spirally  at  intervals  round  the  limb,  and 
by  a  figure-of-8  bandage  which  should  include  the  foot, 


Fig.  120. — Fracture  of  the  femur  in  a  child.  Note  Bradford 
frame  on  which  child  rests.  Note  coaptation  splints,  extension, 
weight,  and  pulley  (Scudder). 

but  leave  the  heel  free.  If  the  foot  is  not  bandaged  also, 
it  is  apt  to  become  edematous.  The  free  ends  of  the  ad- 
hesive strips  are  then  passed  through  the  buckles  on  the 
stirrup  and  the  apparatus  is  complete. 

The  foot  of  the  bed  is  raised  on  blocks;  in  this  position 
the  weight  of  the  body  pulls  against  the  weights  of  the 
extension,  forming  counterextension  at  the  point  at  which 
the  extension  is  applied.  The  head  should  be  low,  one 
flat  pillow  only  being  allowed.  The  pulley,  as  a  rule, 


EXTENSION  321 

should  be  at  a  sufficient  height  to  prevent  the  heel  resting 
on  the  bed.  The  adjustment  of  the  pulley  naturally 
alters  the  direction  of  the  traction.  The  height  ordered 
by  the  surgeon  must  be  carefully  maintained. 

In  treating  fracture  of  the  femur  in  young  children 
vertical  extension  is  often  used.  The  pulley,  instead  of 
being  screwed  to  the  lower  rail  of  the  bedstead,  is  attached 
to  a  cross-bar  or  a  strong  frame  the  width  of  the  bed,  and 
about  3  or  4  feet  higher  than  the  height  of  the  mattress. 
The  cord  is  run  through  the  pulley  and  the  weights  at- 
tached in  the  usual  way.  The  cross-bar  is  in  such  a 
position  that  the  legs,  when  elevated,  are  at  right  angles 
with  the  body.  In  the  illustration  the  leg  is  short  enough 
to  be  attached  to  an  iron  cradle  (Saulter's,  see  below). 
Both  limbs  may  be  elevated,  but  the  extension  is  applied 
only  to  the  injured  side.  The  child  must  be  kept  flat  on 
the  back  and  in  a  fixed  position  (see  below). 

The  extension  is  also  used,  but  more  rarely,  for  injuries 
of  the  upper  extremity  involving  the  shoulder-joint  and 
upper  portion  of  the  humerus,  and  in  the  treatment  of 
injuries  and  disease  of  the  knee.  In  all  cases  the  extension 
plaster  is  applied  immediately  below  the  lesion,  and  the 
weight  of  the  body  is  used  as  counterextension. 

The  extension  applied,  the  position  must  be  strictly 
maintained.  With  restless  children  this  is  frequently  not 
possible  without  some  method  of  tying  the  child  on  to  his 
mattress. 

A  practical  restraint  is  made  out  of  wide  cotton  webbing. 
To  a  length  of  webbing  the  width  of  the  chest  two  loops 
are  firmly  sewn,  much  as  a  child's  pair  of  reins  is  made. 
The  arms  are  put  through  the  loops;  a  length  of  webbing 
is  brought  over  the  mattress  through  the  arm  loops,  under 
the  child's  shoulders,  and  secured  by  buckles  or  strong 
safety-pins  to  the  frame  of  the  bedstead  on  either  side. 
Such  a  restraint  may  be  elaborated  in  several  ways.  In- 
stead of  the  webbing  a  sleeveless  jacket  may  be  made  of 
stout  muslin  or  flannel,  with  the  long  length  of  the  webbing 
passed  through  the  arm-holes  in  the  same  way.  The 
jacket  is  a  better  restraint  if  the  child  is  mischievous. 

The  Bradford  frame  is  an  appliance  in  common  use  in 
21 


322 


BANDAGES  AND   SPLINTS 


connection  with  extension  treatment  in  children,  either 
for  fractures  or  for  joint  disease. 

It  consists  of  a  simple  frame  of  gas-piping  about  1  foot 
longer  than  the  child,  and  \  foot  wider  than  the  width 
at  the  shoulders.  Two  pieces  of  canvas  are  stretched 
across  the  frame  from  side  to  side  and  stitched  securely 
in  place.  The  two  canvases  fill  the  frame,  except  exactly 
in  the  center  of  its  length,  where  a  space  from  9  to  12  inches 
is  left.  The  child  is  laid  on  the  frame,  with  the  buttocks 
directly  over  the  space.  A  short  stout  roller  towel  is 
then  closely  pinned  to  the  canvass  on  either  side  of  the 
body  from  the  axilla  to  below  the  crest  of  the  ilium,  pass- 
ing over  the  body,  and  then  fastening  the  child  to  the 
upper  part  of  the  frame.  A  second  towel  is  secured  in 


Fig.  121. — Bradford  bed-frame  for  fixation  of  trunk  in  fracture 
of  the  thigh.  In  this  illustration  straps  are  used  instead  of  the  roller 
towel  (Scudder). 

the  same  way  on  either  side  of  the  sound  leg,  placing  a 
heel  pad  above  the  heel  to  avoid  pressure.  To  the  affected 
limb  the  extension  is  applied. 

In  giving  the  bed-pan  the  frame  is  easily  raised,  and 
the  bed-pan  slipped  into  place  without  disturbing  the 
position  of  the  patient  or  danger  of  sudden  movement 
to  the  injured  part.  The  patient  can  also  be  taken  out  of 
bed  or  moved  out-of-doors  on  the  frame,  the  necessary 
position  and  immobility  still  maintained.  It  is  one  of 
the  most  simple,  inexpensive,  and  practically  efficient  of 
appliances  in  children's  surgical  nursing. 

FRACTURE  BOARDS,  SAND-BAGS,  CRADLES 

Fracture  boards  are  boards  of  wood  of  convenient  width, 
cut  as  long  as  the  width  of  the  bed.  They  are  placed 


STRAPPING  323 

below  the  ordinary  mattress  or  the  spring  mattress,  where 
one  is  used,  across  the  frame  of  the  bed,  to  prevent  sagging 
in  cases  where  a  rigid  position  is  necessary. 

Narrow  sand-bags  of  different  lengths  made  of  stout 
linen  ticking  are  constantly  used  to  help  in  maintaining 
fixed  position.  They  should  be  provided  with  washable 
slip-covers.  When  a  patient  is  restless,  a  towel  may  first 
be  placed  across  the  limb  or  other  part  to  be  fixed,  and 
under  the  sand-bags,  the  sand-bags,  placed  close  on  either 
side  to  prevent  lateral  movement,  will  then,  by  holding 
the  towel  in  place,  also  prevent  upward  movement. 

Cradles  of  stout  wire,  iron,  wood,  or  wicker  work  are 
used  to  prevent  the  bed-clothes  resting  on  the  patient  or  on 
tender  parts.  They  are  formed  of  three  or  more  half  hoops, 
resting  on  flat  runners,  and  kept  in  place  by  cross-pieces. 
A  couple  of  large  cradles  2  feet  long  by  about  18  inches 
high,  placed  over  the  body  from  the  shoulders  to  the  feet, 
are  used  in  making  the  closed  cabinet  in  giving  vapor 
baths,  etc.  Smaller  cradles  are  used  to  protect  one  limb 
or  a  foot,  etc.  Metal  cradles  should  be  wound  with  a 
bandage  to  prevent  rust-marks  on  the  sheets. 

A  special  cradle,  known  as  Saulter's  cradle,  is  furnished 
with  pulleys,  from  which  is  suspended  a  hammock  made 
of  strips  of  webbing  attached  to  a  wooden  frame  (see  illus- 
tration of  fractured  femur  in  a  child,  Fig.  120).  It  is 
used  to  suspend  the  extended  leg,  at  the  same  time  flexing 
the  thigh.  A  back  splint  swung  by  tapes  from  an  ordinary 
cradle  answers  the  same  purpose.  It  is  a  common  posi- 
tion for  fractures  of  the  tibia  and  fibula,  and  permits  the 
patient  more  freedom  of  movement  than  when  the  splint 
is  kept  on  the  mattress  with  lateral  sand-bags. 

STRAPPING 

In  surgery,  adhesive  strapping  is  frequently  used  not 
only  for  fixing  appliances  or  splints,  but  in  order  to  apply 
local  pressure  or  support. 

Adhesive  strapping  is  a  solution  of  rubber,  petrolatum, 
and  diachylon  or  lead  plaster  (p.  153),  spread  on  linen, 
and  applied  directly  to  the  skin;  the  warmth  of  the  body 


324  BANDAGES   AND    SPLINTS 

melts  the  preparation  sufficiently  to  cause  it  to  adhere 
closely.  Zinc  oxid  is  also  used  in  place  of  the  lead  in  the 
preparation.  Applied  for  any  length  of  time  to  one  spot, 
as,  for  example,  in  connection  with  a  Buck's  extension, 
adhesive  plaster  is  apt  to  irritate  the  skin,  sometimes  caus- 
ing an  eczema  difficult  to  cure.  In  such  circumstances 
a  thin  gauze  bandage  may  be  first  applied  closely  to  the 
limb,  and  the  adhesive  plaster  applied  over  it.  This  is 
unsatisfactory,  as  the  weights  of  the  extension  are  apt  to 
pull  the  strapping  out  of  place  and  frequent  reapplication 
is  necessary.  In  some  children's  hospitals  a  closely  fitting 
stocking  of  Canton  flannel  laced  up  the  front  is  used,  over 
which  the  extension  straps  are  applied.  No  traction  is, 
however,  quite  so  good  as  when  the  strapping  is  applied 
directly  on  the  skin.  The  removal  of  strapping  is  painful, 
owing  to  the  wrenching  of  small  hairs  which  have  become 
adherent  to  the  plaster.  To  lessen  this  the  part  may  be 
shaved  before  the  plaster  is  applied.  In  removing,  the 
plaster  should  be  dabbed  with  a  sponge  soaked  in  turpen- 
tine or  ether,  either  of  which  will  partially  dissolve  the 
plaster  and  make  the  removal  less  painful.  Adhesive 
plaster  is  applied  in  strips.  As  it  forms  an  inelastic  ap- 
plication, it  will  cause  constriction  if*  applied  straight 
round  a  limb  or  entirely  encircling  the  body.  The  strips 
should  be  applied  obliquely.  Where  intended  for  support 
or  to  apply  pressure,  two  sets  of  strips  are  applied,  each 
strip  beginning  at  opposite  points,  crossing  the  opposite 
strip  obliquely  and  overlapping  the  lower  strip  one-third 
of  its  width. 

Fracture  of  the  Ribs. — In  the  treatment  of  fracture  of 
the  ribs  an  application  of  adhesive  plaster  is  frequently 
ordered  to  act  as  a  splint  and  prevent  movement  of  the 
broken  ends  of  the  bone.  For  this  purpose  the  strips  of 
strapping  are  cut  2  inches  wide,  and  sufficiently  long  to 
cover  one  side  of  the  chest  from  a  point  beyond  the  back- 
bone behind  to  a  point  beyond  the  sternum  in  front, 
extending  from  the  waist  to  the  axilla.  Where  possible, 
the  patient  should  stand  to  have  the  plaster  applied,  with 
the  arms  hanging  straight  from  the  shoulder.  He  should 
take  a  long  breath  and  "  empty  "  his  lungs,  keeping  them 


STRAPPING 


so  while  the  plaster  is  applied.     In  a  male  patient  the  chest 
is  shaved,  in  a  female  patient  the  breast  is  not  covered. 

Beginning  below  the  axilla,  the  strips  are  passed  ob- 
liquely from  back  to  front  and  front  to  back  alternately, 
crossing  each  other,  each  strip  overlapping  the  one  below 
one-third  of  its  width.  The  application  is  finished  by 
a  straight  strip.  Strapping  applied  in  this  way  is  also 
frequently  used  in  pleurisy,  where  it  relieves  pain  and  to 
some  extent  checks  the  formation  of  fluid. 


Fig.  122. — Strapping  the  ribs  (after  A.  S.  Morrow). 

A  fractured  clavicle  (p.  633)  is  also  frequently  treated 
with  adhesive  strapping.  The  method  is  known  as 
Sayre's  dressing.  Two  long  pieces  of  strapping  are  required 
3  inches  wide.  A  pad  is  placed  in  the  axilla  of  the  affected 
side,  and  a  piece  of  gauze  in  the  bend  of  the  elbow.  The 
hand  is  brought  over  the  chest,  and  made  to  grasp  the 
opposite  shoulder.  One  strip  of  adhesive  strapping  is 
secured  firmly  round  the  upper  arm  of  the  affected  side, 
opposite  the  axilla,  and  passing  over  the  outer  surface  of 
the  arm  across  the  back  and  under  the  opposite  axilla,  is 
brought  across  the  chest  under  the  flexed  arm  and  finished 
below  the  starting-point. 

The  second  strip  starts  at  the  opposite  shoulder,  crosses 
the  back  obliquely,  passes  over  the  point  of  the  elbow  on 


326 


BANDAGES   AND   SPLINTS 


the  affected  side,  and  up  along  the  dorsal  surface  of  the 
forearm  and  hand  over  the  sound  shoulder,  and  finishes  at 
a  point  above  half-way  across  the  back,  sufficient  to  give 
a  firm  hold.  A  small  hole  cut  where  the  point  of  the  elbow 
rests  makes  the  plaster  fit  more  closely.  With  this  ap- 
pliance the  shoulder  is  forced  upward,  backward,  and  out- 
ward, and  the  joint  is  held  in  a  fixed  position.  The  whole 
may  be  further  secured  by  a  wide  roller  bandage  round 
the  chest  and  flexed  arm. 


Fig.  123. — Sayre's  dressing:  a,  First  strip;  b,  second  strip,  front  and 
back  views  (Beck). 

Chronic  ulcers  of  the  leg  are  frequently  treated  success- 
fully by  strapping;  the  application  is  made  in  the  same  way 
as  in  strapping  the  chest,  the  strips  crossing  each  other 
obliquely  and  not  entirely  encircling  the  limb.  The  strips 
should  be  about  \  inch  wide.  For  appearance  sake  the 
ends  should  be  cut  even  and  covered  by  a  straight  strip 
at  either  side.  The  leg  should  be  kept  elevated,  and  the 
plaster  renewed  every  four  or  six  days. 

Sprains. — Strapping  is  also  used  as  a  local  support 
and  to  apply  pressure  in  the  treatment  of  sprains.  They 
are  usually  applied  in  a  modified  figure-of-8,  care  being 
taken  not  completely  to  encircle  the  joint  with  any  one 
strip.  The  strips  are  cut  about  1  inch  wide,  and  suffi- 
ciently long  to  be  carried  obliquely  around  the  limb,  cross 
in  front,  and  continue  half  round  the  limb  again.  If  a 
straight  strip  is  used  to  finish  it,  the  ends  should  not 
meet. 


KNOTS 


327 


To  Strap  an  Ankle. — To  strap  an  ankle  two  sets  of  ad- 
hesive strips  are  used.  The  first  set  is  applied  like  a 
stirrup,  below  the  heel,  and  up  either  side  of  the  ankle 
to  a  point  beyond  the  swelling.  The  second  set  is  applied 
over  the  first  from  the  back  of  the  ankle  toward  the 
instep,  each  strip  crossing  the  one  below  at  right  angles. 


Fig.  124. — Strapping  an  ankle-joint  (after  A.  S.  Morrow). 


Strapping  Wounds. — Where  strapping  is  used  in  place 
of  stitches  to  bring  the  edges  of  wounds  together,  the 
strips  should  be  cut  sufficiently  long  to  grip  firmly  the 
tissues  on  either  side.  The  strips  are  attached  on  either 
side  and  brought  across  to  the  opposite  side  alternately, 
crossing  over  the  wound,  which  should  not  be  completely 
covered. 

An  abdominal  dressing  is  sometimes  kept  in  place  by 
broad  strips  of  strapping  to  which  tapes  are  firmly  sewn. 
Three  strips  are  applied  to  either  flank,  and  the  tapes  tied 
together  over  the  dressing.  At  first  a  Scultetus  bandage 
is  applied  over  the  strips,  but  if  there  is  no  oozing,  this  is 
discarded  after  the  second  day,  usually  to  the  relief  of  the 
patient. 

KNOTS 

The  Granny  Knot. — This  is  the  tie  knot  in  domestic  use. 
It  has  the  disadvantage  of  readily  slipping  if  subjected  to 


328  BANDAGES   AND   SPLINTS 

strain.     In  surgical  work  the  granny  knot  is  replaced  by 
the  reef  knot  and  the  surgeon's  knot. 

Reef  Knot. — The  first  twist  of  a  reef  knot  is  the  same  as 
the  granny  knot.  In  a  granny  knot  the  second  twist  is 
made  by  bringing  the  free  end  lying  behind  forward,  and 
crossing  it  over  the  other  in  front;  in  a  reef  knot  for  the 


Fig.   125. — Method  of  tying        Fig.  126. — Method  of  tying  square 
granny  knot  (DaCosta).  or  reef  knot  (DaCosta). 

second  twist  the  free  end  lying  in  front  is  held  in  front,  and 
passed  from  the  front  backward  over  the  end  lying  behind 
and  coming  out  through  the  loop.  In  this  way  the  free 
ends  of  the  loop  are  parallel  to  the  loop,  whereas  in  a  granny 
knot  they  lie  at  right  angles.  The  loops  of  a  reef  knot 
will  not  slip,  however  great  the  strain,  provided  the  ends 
forming  the  knot  are  of  the  same  thickness. 


Fig.  127. — Method  of  tying  surgeon's  knot  (DaCosta). 

In  the  surgeon's  knot  the  ends  are  crossed  and  each 
twisted  once — the  right  to  the  left  and  the  left  to  the  right 
of  the  point  at  which  they  cross.  It  is  used  in  many  cir- 
cumstances, such  as  ligation,  strangulation,  etc.  Very 
commonly  a  combination  of  reef  and  surgical  knot  is  used, 
especially  in  sutures. 


KNOTS  329 

Clove-hitch. — A  clove-hitch  forms  a  double  loop,  which 
is  pulled  tight  by  traction  on  the  free  ends.  There  are  a 
variety  of  ways  of  holding  and  twisting  the  cord  or  band- 
age to  form  the  hitch;  the  following  is  as  simple  as  any: 

1.  Hold  the  cord  at  a  convenient  interval  between  finger 
and  thumb  of  either  hand,  the  hands  lying  palms  upward, 
the  free  ends  of  the  cord  hanging  from  the  thumb  side. 

2.  Holding  the  cord  firmly,  turn  the  hands  knuckles 
upward,  bringing  the  thumbs  opposite  each  other.     The 
free  ends  are  then  hanging  on  the  further  side  of  the  cord 
from  the  operator. 

3.  With  one  movement  pass  the  free  end  on  the  right 
hand  over  the  cord  toward  the  operator:  the  ends  are 
then  on  either  side  of  the  cord. 


Fig.  128.— Clove-hitch  knot  applied  (Erichsen). 


4.  Without  moving  the  ends  or  twisting  either  of  the 
loops,  pass  the  loop  from  the  left  hand  on  to  the  fingers  of 
the  right  and  the  hitch  is  made.  The  position  of  the  hands 
must  not  be  changed  in  this  movement,  the  knuckles  of 
the  left  hand  must  stay  uppermost,  with  the  thumb 
toward  the  operator;  the  usual  mistake  is  to  turn  the  left 
hand.  When  complete,  each  free  end  forms  a  loop,  one  in 
front  and  one  behind  the  central  cord,  and  crosses  the 
other  over  the  central  cord. 

Where  there  is  much  awkwardness  in  learning  the  knots, 
a  red  and  white  tape  knotted  together  used  to  demonstrate, 
generally  makes  them  more  readily  understood. 


CHAPTER  IX 
MEDICINES 

Weights  and  Measures — The  Metric  System — Names  of  Prepa- 
rations— Terms  in  Common  Use— Dosage — Time  of  Administration 
— Average  Dose  of  Commonly  Used  Medicines — Table  of  Abbrevia- 
tions— Table  of  Familiar  Preparations — Methods  of  Administration. 

THE  chief  duties  of  a  nurse  in  administering  medicines 
are  to  measure  accurately,  to  give  punctually,  and  to 
observe  the  effects.  To  accomplish  the  first  she  must 
understand  the  measures  in  common  use;  for  the  latter  she 
must  have  a  sound,  however  elementary,  knowledge  of 
the  physiologic  action  of  the  drugs  employed.  Wherever 
possible,  teaching  on  this  important  subject  should  be 
given  at  an  early  date  in  the  pupil's  training.  As,  how- 
ever, the  observation  of  the  effects  of  a  drug  is  never  left 
exclusively  to  pupil  nurses,  it  is  reasonable  and  practical 
to  permit  a  young  nurse  to  administer  medicines  once 
she  understands  how  to  measure  them,  and  her  sense  of 
responsibility  and  her  accuracy  have  been  adequately 
tested.  A  pupil  should  not  be  put  in  any  position  of  higher 
responsibility,  such  as  a  senior  nurse  in  a  ward,  before  she 
has  a  working  knowledge  of  the  effects  of  the  drugs  the 
use  of  which  she  will  be  expected  to  supervise. 

WEIGHTS  AND  MEASURES 

For  the  weighing  and  measuring  of  drugs  two  systems 
are  in  use,  the  apothecaries  and  the  metric.  The  apoth- 
ecaries is  still  in  general  use  in  America  and  in  Great  Britain, 
though  the  use  of  the  metric  system  is  gradually  gaining 
ground. 

Apothecary  measures  are  as  follows : 

Apothecaries1  Weight. 
20  grains  =     1  scruple. 

3  scruples,  or  60  grains     =     1  dram  or  drachm. 

8  drams  =      1  ounce. 

12  ounces  =     1  pound. 

330 


WEIGHTS    AND    MEASl'HKS  331 

Apothecaries'  Fluid  or  Wine  Measure. 

60  minims  =  1  fluidram  or  fluidrachm. 

8  fluidrams  =  1  fluidounce. 

16  fluidounces  =  1  pint. 

8  pints  =  1  gallon. 

To  express  these  measures,  signs  are  employed  as  follows : 

Scruple 9 

Dram z 

Ounce .5 

Pound tb,   an  abbreviation  of  the  Latin  libra. 

Minim 1TL 

Pint O,    abbreviation  of  Latin  octarius,  a  pint  being  the 

eighth  part  of  a  gallon. 
Gallon C,    abbreviation  of  Latin  congius. 

When  the  sign  is  used,  the  numeral  denoting  the  quan- 
tity follows  the  sign,  Latin  numerals  being  invariably  used : 
thus,  Oij,  or  2  pints;  5j,  or  1  ounce.  When  half  the 
quantity  expressed  by  a  sign  is  to  be  signified,  the  Latin 
word  for  half,  semis,  abbreviated  to  ss,  is  commonly  used. 
For  example,  30  minims  is  equivalent  to  half  a  dram;  it 
may  be  written  equally  correctly  as  TTlxxx  or  as  5ss. 
Should  the  half  be  used  with  a  whole  number,  the  ss  is 
placed  directly  after  the  numeral,  without  the  repetition 
of  the  sign  thus — oiss,  5iiss,  Oiss. 

The  scruple  is  little  used  in  measuring  medicines,  the 
fractional  parts  of  a  dram  usually  being  expressed  in 
minims  where  fluids,  and  grains  where  solids,  are  under- 
stood. 

Avoirdupois. — Some  confusion  is  occasionally  met  with 
in  regard  to  terms  which  are  the  same  in  apothecaries' 
measures  and  in  others.  The  common  blunders  are  be- 
tween the  pound  avoirdupois  and  the  pound  apothecary, 
and  between  the  imperial  pint  and  the  pint  of  the  Ameri- 
can apothecaries'  measure. 

Avoirdupois  Weight. 
27.34  grains  1  dram. 

16  drams  =     1  ounce. 

16  ounces  1  pound, 

whereas  the  apothecaries'  measure  employs  the  troy  table, 
in  which  12  ounces  make  one  pound. 


332  MEDICINES 

Avoirdupois  is  not  used  in  measuring  drugs,  but  may  be 
met  with  by  the  nurse  in  weighing  bulk,  such  as  tumors, 
new-born  infants,  etc.  Where  the  avoirdupois  scale  is 
used,  the  word  avoirdupois  should  be  written  after  the 
weight. 

The  pint  of  the  standard  liquid  measure  contains  20 
fluidounces,  each  ounce  being  equal  to  8  fluidrams.  This 
pint  is  derived  from  a  fixed  measure  of  weight,  the  gallon, 
of  which  the  pint  is  an  eighth  part,  being  equivalent  to 
10  pounds  of  water  at  its  greatest  density  (4°  C.).  In 
America  the  apothecaries'  measure  has  for  convenience 
adopted  16  ounces  as  the  equivalent  of  the  fluid  pint,  the 
same  number  of  ounces  as  in  the  pound  avoirdupois. 
Where  the  standard  pint  is  intended,  it  is  distinguished 
as  the  Imperial  pint.  In  other  countries  the  standard 
pint  of  20  ounces  is  used,  which  may  cause  confusion  if  the 
difference  is  not  understood. 

The  Drop. — It  must  be  remembered  that  the  minim  is 
an  official  drop  of  a  fixed  standard,  whereas  the  natural 
drop  formed  by  liquids  varies  in  bulk  with  the  density  of 
the  liquid.  Where  the  natural  drop  is  intended  the  word 
gutta  (gtt.)  is  used  instead  of  minums.  Approximately 
in  measuring  water  or  aqueous  fluids  a  drop  is  equal 
to  a  minim;  for  alcohol  solutions,  such  as  tinctures,  two 
drops  form  the  minim;  while  volatile  drugs,  such  as  ether 
or  chloroform,  count  about  4  drops  to  the  minim.  On 
the  other  hand,  a  drop  of  a  gummy  or  syrupy  substance 
is  larger  than  a  minim. 

Tables  giving  the  exact  number  of  drops  to  a  minim  of 
any  drug  will  be  found  in  most  text-books  on  materia 
medica. 

Where  the  sign  minim  is  used  with  an  order,  the  drug 
must  invariably  be  measured  in  a  minim  glass;  at  the 
same  time  it  is  inaccurate  to  use  a  minim  measure  if 
gutta  are  ordered.  Drops,  or  gutta,  are  best  measured 
with  a  pipet  fitted  with  a  rubber  cap  or  nipple,  by  compress- 
ing which  gently  the  liquid  is  forced  out  in  drops  of  equal 
size. 

Where  lesser  quantities  than  the  grain  or  minim  are 
required,  the  amount  is  expressed  in  fractions.  Thus 


WEIGHTS   AND    MEASURES  333 

we  may  have  half  a  minim,  an  eighth  of  a  grain,  and  so 
forth. 

Fractional  Doses. — A  little  practice  is  often  necessary 
to  teach  pupils  to  reckon  accurately  the  total  amount  taken 
of  a  drug  given  in  fractional  doses.  Where  each  dose  is  of 
equal  value,  the  denominator  is  multiplied  by  the  number 
of  doses:  thus,  y-g-  repeated  four  times  equals  T\  or  \. 
Where  the  fractions  are  of  mixed  values,  the  common 
denominator  must  first  be  sought,  each  numerator  multi- 
plied by  the  number  of  times  its  denominator  is  contained 
in  the  common  denominator,  and  the  results,  added  to- 
gether, placed  over  the  common  denominator. 

Thus,  to  add  -fa  +  -jV  +  yV  The  common  denominator 
being  60,  the  sum  stands 

1+2  +  4        7_ 
60  60' 

Practice  should  also  be  given  in  preparing  fractional 
doses  from  preparations  of  a  different  fractional  value. 
Thus,  a  dose  of  -fa  may  be  ordered  where  the  stock  solu- 
tion is  made  up  in  the  strength  of  T^  in  every  so  many 
minims,  usually  10  or  12.  To  find  the  required  dose 
the  strength  of  the  stock  solution  is  multiplied  by  the 
number  of  minims  in  which  it  is  contained,  and  the  result 
is  divided  by  the  strength  of  the  dose  required.  For  ex- 
ample, suppose  a  stock  solution  to  contain  y^-  grain  in 
every  10  minims  and  we  wish  to  give  a  dose  of  -fa  of  a 
grain,  the  sum  is  worked  as  follows: 

100  X   10  =   1000  :  1000  -*•  80  =   12J. 

Twelve  and  a  half  minims  will  contain  -£-$  grain  of  the  drug. 
Where  drugs  are  put  up  in  tablet  form,  the  same  method 
may  be  carried  out,  the  tablet  first  being  dissolved  in  a 
given  number  of  minims. 

Measuring-glasses. — In  administering  medicines  grad- 
uated measures  are  used,  on  which  the  measurements  corre- 
spond exactly  to  the  apothecaries'  fluid  measure.  The  use 
of  spoons  or  cups  in  place  of  the  graduated  measure  tends 
to  inaccuracy,  and  should  not  be  permitted.  Approx- 


334  MEDICINES 

imately,  apothecaries'  measure  corresponds  to  domestic 
measures  as  follows: 

1  teaspoon  =  1  dram. 

1  dessertspoon  =  2  drams. 

1  tablespoon  =  \  ounce. 

1  wineglass  =  2  ounces. 

1  cupful  =  4  to  5  ounces. 

1  tumblerful  =  8  to  10  ounces. 

THE  METRIC   SYSTEM 

The  metric  system  of  measuring  originated  in  France 
about  the  end  of  the  eighteenth  century,  and  is  at 
present  the  only  one  in  use  on  the  continent  of  Europe. 
It  is  universally  used  in  scientific  work,  and  is  coming 
more  and  more  into  general  use  in  medicine  in  America. 
In  the  medical  department  of  the  United  States  Army  it 
is  used  entirely  in  place  of  the  apothecaries'  weights  and 
measures. 

The  metric  system  is  a  decimal  system,  like  the  decimal 
system  of  coinage,  of  which  the  American  symbols  are 
the  dollar,  dime,  and  cent.  The  fractions,  that  is  to  say, 
are  all  tenth,  hundredth,  or  thousandth  parts  of  the  unit, 
which  is  represented  in  the  United  States  coinage  by  the 
dollar. 

To  illustrate  simply  this  essential  difference  between  the 
fraction  in  ordinary  use  and  those  of  the  decimal  or  metric 
system,  take  the  sum  of  a  dollar  and  twenty-five  cents. 
By  ordinary  reckoning  the  so-called  vulgar  fractions,  we 
may  describe  the  sum  as  one  dollar  and  a  quarter,  twenty- 
five  cents  being  \  the  value  of  the  unit  or  dollar.  By 
decimal  fractions  the  same  sum  is  expressed  as  one  dollar 
twenty-five  cents  ($1.25),  that  is  one  dollar,  two-tenths, 
and  five-hundredths  of  a  dollar,  or,  more  simply,  twenty- 
five  hundredths  of  a  dollar. 

The  advantages  of  the  metric  system  are  in  the  greater 
facility  it  presents  for  calculating,  especially  in  multi- 
plying and  dividing,  and  that  it  makes  possible  a  common 
scale  for  measures  of  length,  weight,  and  volume. 

The  Measure  of  Length. — The  parent  measure  on  which 
the  others  are  based  is  the  measure  of  length.  To  obtain 
this  the  polar  circumference  of  the  earth  is  taken  as  a 


THE   METRIC   SYSTEM  335 

fixed  measure,  and  the  ten-millionth  part  of  one-quarter  of 
the  circumference  is  taken  as  the  unit.  This  measure  is 
called  the  meter,  from  the  Greek  metron,  a  measure.  It 
measures  a  little  over  39  inches.  Following  the  decimal 
system,  the  meter  is  subdivided  into  tens,  hundreds,  and 
thousands,  instead  of,  as  in  the  yard,  into  feet  and  inches. 
These  divisions  are  named  by  placing,  before  the  word 
meter,  the  Latin  prefixes  deci-  (10),  centi-  (100),  milli- 
(1000).  As  in  coinage,  the  fraction  is  expressed  by  a  point 
placed  after  the  unit  and  before  the  fraction,  and  the  value 
of  the  fraction  by  its  place  after  the  point.  Thus,  tenths 
are  expressed  as  0.1;  hundredths,  as  0.01;  and  thousandths 
as  0.001.  For  example,  0.257  of  a  meter  represents  T2T 
+  TFO  +  TT<ro>  or  2  decimeters,  5  centimeters,  and  7 
millimeters;  or,  more  simply,  257  millimeters. 

The  measure  most  constantly  met  with  is  the  centimeter, 
which  takes  the  place  of  the  inch  in  the  yard  measure, 
and  measures,  approximately,  f  inch.  For  the  multipli- 
cation of  the  meter  the  Greek  prefixes  deka-  (10),  hekto- 
(100),  and  kilo-  (1000)  are  placed  before  the  word  meter. 
A  kilometer  thus  is  a  measure  of  1000  meters. 

The  divisions  of  the  meter  most  frequently  used  com- 
pare approximately  with  ordinary  lineal  measure,  as 
follows: 

1  millimeter  =  2V  inch. 

1  centimeter  =  f  inch. 

1  decimeter  =  4  inches. 

1  meter  39.37  inches. 

1  kilometer  =  3280  feet  7  inches,  or  about  J  mile. 

The  same  prefixes,  deci-,  centi-,  and  milli-,  for  the  divis- 
ions, and  deka-,  hekto-,  and  kilo-,  for  the  multiplications, 
are  used  before  the  unit  in  the  measures  of  weight,  capacity, 
and  volume,  based  on  the  meter. 

The  measure  of  capacity  is  derived  from  the  cube  of 
the  meter.  A  cube  is  a  body  measuring  exactly  the  same 
in  its  three  dimensions  of  length,  breadth,  and  height. 
For  example,  while  the  term  1  meter  signifies  a  line  1 
meter  in  length,  1  cubic  meter  represents  a  body,  or  a 
space,  which  measures  1  meter  in  length,  breadth,  and 
height. 


336  MEDICINES 

Where  the  cube  is  intended,  the  word  cubic  is  placed 
before  the  prefixes  of  multiplication  or  division;  thus, 
cubic  millimeter,  cubic  centimeter,  etc. 

The  Measure  of  Volume. — The  name  liter  is  given  to 
the  unit  of  the  measure  of  volume;  it  corresponds  approx- 
imately to  the  quart,  or  two  pints.  The  liter  represents 
the  capacity  of  a  cube  measuring  1  decimeter  (one-tenth 
of  a  meter)  in  each  of  its  three  dimensions,  that  is,  one 
cubic  decimeter  (approximately,  4  cubic  inches),  by  which 
term  it  might  equally  well  have  been  known.  Using  the 
same  prefixes  that  are  used  in  the  multiplication  and 
divisions  of  the  meter,  we  have  the  deciliter,  centiliter, 
and  milliliter,  the  dekaliter,  hectoliter,  and  kiloliter. 

The  measure  of  capacity  is  equally  the  measure  of 
volume,  and  is  used  in  measuring  fluids,  the  liter  rep- 
resenting the  volume  of  water  required  to  fill  a  cube  of 
that  capacity.  For  these  measurements  water  is  taken 
at  its  greatest  density,  which  is  4°  C.  From  its  size, 
however,  the  liter  is  an  inconvenient  standard  where  small 
amounts  and  their  fractions  have  to  be  reckoned.  It 
would  obviously  be  impractical  to  describe  the  minim  or 
the  dram  as  fractional  parts  of  a  quart.  To  overcome 
this  disadvantage,  in  place  of  the  subdivisions  of  the  liter 
we  use  the  cube  of  the  centimeter,  which  is  equal  to  one 
milliliter.  This  represents  the  volume  of  water  at 
4°  C.  required  to  fill  a  cube  measuring  1  centimeter  (f 
inch)  in  each  of  its  three  dimensions.  This  measure  is  the 
ordinary  medicinal  unit,  and  is  used  entirely  in  place  of 
the  subdivisions  of  the  liter.  Thus,  instead  of  one  deciliter, 
we  say  100  cubic  centimeters.  A  liter  also  is  frequently 
described  as  1000  cubic  centimeters. 

The  apothecaries'  fluid  measures  are  expressed  in  cubic 
centimeters,  as  follows: 

Approximately.  Accurately. 


1  minim 

_ 

0.06  c.c. 

15  minims 
1  fluidram 
1  fluidounce 
1  pint 
1  quart 

= 

Ice. 
4  c.c. 
30  c.c. 
500  c.c. 
1000  c.c.  or  1  liter 

0.92  c.c. 
3.75  c.c. 
29.57  c.c. 
473.11  c.c. 
950.22  c.c. 

THE    METRIC    SYSTEM  3l>7 

Metric  Weights.— The  unit  of  weight  is  the  weight  of 
one  cubic  centimeter  of  water  at  its  greatest  density  (4°  C.). 
To  this  unit  the  name  gram  has  been  given.  Thus,  one 
cubic  centimeter  of  water  by  measure  equals  one  gram  of 
water  by  weight. 

The  multiplications  and  divisions  of  the  gram  are  also 
expressed  by  the  prefixes  mentioned  above,  i.  e.,  the  deci- 
gram, centigram,  and  milligram,  the  dekagram,  hektogram, 
and  kilogram. 

The  metric  measure  of  weight  corresponds  to  the  other 
measures  of  weight  as  follows: 

Apothecaries'  Measure. 

Approximately.  Accurately. 

1  grain  65  milligrams  0.065  gm. 

15  grains  1  gram  0.972  gm. 

1  dram                                          4  grams  3.900  gm. 

4  drams  or  ^  an  ounce  15  grams  15.500  gm. 

1  ounce  30  grams  31.100  gm. 

12  ounces  or  1  pound  400  grams  373.230  gm. 

Avoirdupois. 

I  ounce                                      30  grams  28.35  gm. 

1  pound                                     450  grams  453.60  gm. 

2  pounds  2  ounces            =      1000.00  gm. 

or  1  kilogram. 

Arabic  numerals  are  used  instead  of  the  Latin  ones,  and 
the  measure,  represented  either  by  its  initial  letter  or  an 
abbreviation,  is  placed  after  the  number:  thus,  15  gm., 
200  c.c.;  in  writing  prescriptions  the  former  is  usually 
omitted,  gm.  being  understood.  Thus,  a  dose  of  a  drug 
may  be  written  simply  0.65,  signifying  0.65  gram. 

The  Common  Metric  Measures. — The  measures  of  the 
metric  system  in  most  common  use  and  their  signs  are  as 
follows : 

The  meter M. 

Centimeter cm. 

Millimeter mm. 

Cubic  centimeter c.c. 

Liter L. 

Gram gm. 

Kilogram K. 

Approximate  Values  of  Metric  Measures. — As  a  rough 
estimate  in  measuring  and  weighing  drugs  the  following 


338  MEDICINES 

approximate  values  of  the  measures  in  most  common  use 
are  generally  accepted: 

500  c.c.  for    1  pint  (American). 
500  gm.  for    1  pound  (avoirdupois). 
30  c.c.  for    1  fluidounce. 
30  gm.  for    1  ounce  by  weight. 
4  c.c.  for    1  fluidram. 
4  gm.  for    1  dram  by  weight. 
1  c.c.  for  15  minims. 
1  gm.  for  15  grains. 

Changing  Apothecaries'  to  Metric. — Frequently  it  may 
be  of  use  to  express  a  dose  measured  by  apothecaries' 
measure  by  the  metric  system.  To  do  so,  the  simplest 
method  is  to  reduce  the  dose  to  minims  or  grains  and  divide 
by  15,  the  approximate  number  of  minims  or  grains  in  the 
cubic  centimeter  or  gram  respectively.  If  the  bulk  is 
large,  it  may,  instead,  be  reckoned  in  drams  and  divided 
by  4,  the  number  of  cubic  centimeters  or  grams  in  a  dram. 

To  express  portions  of  a  grain  in  grams  two  methods 
can  be  used.  It  will  be  remembered  that  the  grain  is 
equal  to  0.065  gm.,  or  65  milligrams.  Half  a  grain, 
therefore,  represents  33  milligrams  (0.033  gm.);  \  grain, 
16  milligrams  (0.016) ;  J,  20  milligrams  (0.02),  and  so  forth. 

A  second  and  more  convenient  working  method  is  to 
express  the  fraction  as  a  decimal,  and,  as  in  other  doses, 
to  divide  by  15.  For  example,  f  expressed  in  decimal 
fractions  is  0.37,  which,  divided  by  15,  is  0.025.  A  dose 
of  f  grain  is,  therefore,  represented  by  the  metric  system 
as  0.025  gram,  or  25  milligrams. 

In  some  tables,  comparing  doses  by  vulgar  fractions 
with  fractional  doses  by  metric  measure,  the  calculation 
is  made  with  15|  instead  of  with  15.  The  difference  of 
the  dose  is  so  extremely  small  that  the  more  convenient 
15  is  generally  allowed  as  sufficiently  accurate. 

NAMES   OF  PREPARATIONS 

The  tables  and  measures  having  been  mastered,  the 
different  forms  in  which  drugs  are  made  up  should  next 
be  studied.  The  actual  preparation  should  be  used, 
with  which  the  pupils  should  be  made  familiar  by  observ- 
ation, smell,  and,  where  practical,  taste.  At  the  same  time 


339 

a  simple  general  classification  of  the  drugs  used  into  the 
animal,  vegetable,  or  mineral  kingdoms  can  be  made: 


Infusum  (Infus.). 

Glyceritum  (Glyc.). 

Extractum  (Ext.). 
Fluid  extractum  (Fl.  ex.). 

Decoctum  (Decoc.). 
Elixir  (Elix.).. 
Emplastrum  (Emplas.). 
Emulsum. 

Confectio  (Conf.). 

O>- 

2>° 

&e 

p;  
Pg 

Abstractum  (Abstr.). 
Acetum. 

ir" 

Infusion. 

Glycerite. 

Solid  extract. 
Fluidextract. 

Emulsion. 

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NAMES  OF   PREPARATIONS  341 

Drugs  in  either  powdered  or  fluid  form  are  also  put  up 
in  minute  gelatin  boxes  or  capsules,  which  melt  at  the  tem- 
perature of  the  stomach. 

Other  terms  frequently  met  with  in  medicine  which  it 
is  necessary  to  understand  are  as  follows: 

Element.—  That  which  cannot  be  divided  or  reduced 
to  a  simpler  form.  Ex.:  oxygen,  iron,  carbon,  etc. 

Chemical  Compound. — The  union  of  two  or  more  elements 
to  form  a  new  substance,  in  which  the  elements  completely 
lose  their  identity.  Ex. :  hydrogen  and  oxygen  combined 
form  water. 

Base. — The  fundamental  element  of  a  mixture. 

Acids. — The  chemical  compounds  of  hydrogen  are 
known  as  acids,  it  is  supposed,  on  account  of  their  sharp 
taste. 

Salts. — -The  union  of  an  acid  with  a  base  is  known  in 
chemistry  as  a  salt.  Ex.:  morphin  sulphate. 

Alkaloid. — The  active  principle  of  a  drug.  Ex.:  mor- 
phine, of  opium;  atropin,  of  belladonna.  The  alkaloids 
unite  with  acids  to  form  salts,  in  which  condition  they  are 
soluble  in  water.  Ex.:  morphin  sulphate. 

Alkali. — -A  caustic  base  having  certain  properties;  it 
saponifies  fat,  turns  litmus-paper  blue,  is  soluble  in  water, 
and  unites  with  acids  to  form  salts.  The  alkali  metals 
are  potassium,  lithium,  sodium,  and  ammonium. 

A  large  variety  of  names  are  used  to  describe  the  physio- 
logic effect  of  a  drug.  The  following  are  a  few  of.  the 
most  important: 

Analgesic. — A  drug  taken  internally  to  relieve  pain. 

Anesthetic. — -A  drug  causing  local  insensibility,  or, 
taken  internally,  general  unconsciousness. 

Anodyne.— A  drug  applied  locally  to  relieve  pain. 

Anthelmintic  (Teniacide). — A  drug  that  expels  worms. 

Antihydrotic. — A  drug  which  diminishes  sweat. 

Antipyretic. — A  drug  that  reduces  fever. 

Aperient. — A  drug  that  opens  the  bowels. 

Astringent. — A  drug  causing  contraction  of  organic 
tissue,  thereby  lessening  secretions. 

Carminative. — A  drug  that  disperses  gas  in  the  stomach 
or  intestines. 


342  MEDICINES 

Cathartic  (Purgative). — A  powerful  aperient. 

Cholagogue. — A  drug  which  increases  the  secretion  of 
bile. 

Diaphoretic  (Sudorific). — A  drug  which  increases  the 
secretion  of  sweat. 

Diuretic.— A.  drug  which  increases  the  secretion  of 
urine. 

Ecbolic  (Oxytocic}.— A  drug  which  stimulates  the  con- 
tractions of  the  uterus. 

Emetic. — A  drug  which  causes  vomiting. 

Emmenagogue. — A  drug  which  stimulates  menstrua- 
tion. 

Epispastic  (Vesicant). — A  drug  which,  applied  locally, 
produces  a  blister. 

Expectorant. — A  drug  which  stimulates  the  secretion 
of  the  organs  of  respiration. 

Galactagogue. — A  drug  which  increases  the  secretion  of 
milk. 

Hemostatic. — A  drug  which  causes  the  arrest  of  hemor- 
rhage. 

Hydragogue. — A  drug  which  produces  watery  evacua- 
tions. 

Hypnotic  (Narcotic;  Soporific;  Somnifacient). — A  drug 
which  produces  sleep. 

Mydriatic. — A  drug  which  dilates  the  pupil. 

Myotic. — A  drug  which  contracts  the  pupil. 

Sedative. — A  drug  which  quiets  the  nervous  system 
without  actually  producing  sleep. 

Sialagogue  (Ptyalagogue) . — A  drug  which  increases  the 
secretion  of  saliva. 

DOSAGE 

The  dosage  of  a  drug  is  modified  to  some  extent  by 
age,  sex,  individuality,  idiosyncrasy,  and  race. 

Age. — Children  and  old  people  require  proportionately 
less  of  a  drug  than  adults.  No  fixed  rule  for  determining 
the  dose  for  a  child  according  to  its  age  is  invariably 
reliable;  the  following,  known  as  Young's  rule,  is,  how- 
ever, frequently  used: 


DOSAGE  343 

To  the  years  of  age  add  twelve,  divide  the  sum  by  the 
age,  and  take  the  result  as  the  proportion  of  the  adult  dose. 
Example:     For  a  child  six  years  old: 

6  +  12  =  -1/  =  3.     The  dose  is  $  that  for  an  adult. 

Some  drugs,  such  as  opium,  however,  act  on  a  child  rela- 
tively more  powerfully  than  on  an  adult.  For  such 
drugs  half  the  dose  estimated  by  Young's  rule  is  usually 
the  maximum  considered  safe.  For  laxatives,  on  the 
other  hand,  a  larger  proportion — from  J  to  f  more  than 
by  Young's  rule — is  usually  necessary. 

Sex. — Speaking  generally,  men  tolerate  larger  doses 
of  drugs  than  women. 

Individuality. — Some  individuals  are  peculiarly  sus- 
ceptible to  drugs,  and  require,  therefore,  doses  smaller 
than  the  average. 

Idiosyncrasy. — Persons  are  met  with  who  become 
quickly  poisoned  by  certain  foods,  taken  by  the  majority 
with  impunity;  some,  for  example,  are  poisoned  by  the 
smallest  portion  of  mushroom.  The  same  idiosyncrasy 
is  also  sometimes  displayed  toward  drugs,  and,  if  not 
previously  known,  may  lead  to  accidents.  Some  have  an 
intolerance  for  opium,  a  small  dose  producing  toxic  symp- 
toms. For  this  reason,  if  a  nurse,  in  a  serious  emergency, 
is  left  to  her  own  resources  and  obliged  to  use  a  powerful 
drug,  she  should  be  extremely  careful  to  give  the  smallest 
dose  possible,  until  she  has  observed  the  physiologic  effect. 

Race. — Race  influences  dosage  to  a  certain  extent. 
The  colored  races,  for  example,  tolerate  larger  doses  of 
many  medicines  than  the  white  race. 

The  action  of  a  drug  may  also  be  modified  by  many  cir- 
cumstances, such  as  fasting,  pain,  the  physical  condition 
of  the  patient,  the  time  at  which  the  drug  is  given,  the 
method  by  which  it  is  given,  the  accumulative  property 
of  a  special  drug,  or  tolerance  established  by  the  use  of  a 
drug. 

A  drug  taken  fasting  will  act  more  quickly  and  more 
powerfully  than  if  taken  on  a  full  stomach.  For  example, 
a  dose  of  alcohol  which  will  intoxicate  if  taken  fasting,  is 
tolerated  if  taken  with  a  meal. 


344  MEDICINES 

Where  pain  is  acute,  proportionately  larger  doses  of  a 
narcotic  or  anodyne  may  be  required  to  produce  results 
usually  obtained  by  a  smaller  dose.  Similarly,  in  con- 
ditions of  shock  or  collapse  abnormally  large  doses  of  stim- 
ulants are  tolerated.  A  drug  intended  as  an  antidote  is 
also  given  in  doses  larger  than  normal. 

By  toleration  is  understood  the  tendency  of  the  system 
to  become  habituated  to  the  action  of  a  drug  when  ad- 
ministered over  lengthy  periods,  so  that  to  some  extent 
it  loses  its  effect  and  increased  doses  are  necessary  to 
obtain  results.  Narcotics,  sedatives,  anodynes,  all  pro- 
duce toleration. 

The  action  of  volatile  drugs,  as,  for  example,  ammonia 
and  the  nitrites,  is  prompt,  and  the  effect  passes  quickly. 
Such  drugs  must  be  given  more  frequently  than  drugs  that 
act  slowly  and  produce  more  persistent  effects.  Drugs 
that  are  slowly  absorbed  and  eliminated  are  given  at 
greater  intervals,  otherwise,  though  the  individual  dose 
may  be  small,  too  much  of  the  drug  may  be  present  at 
one  time  in  the  system  and  produce  symptoms  of  overdose. 
Digitalis  is  an  example  of  such  a  drug. 

Certain  drugs  have  also  a  tendency  to  accumulate  in 
the  system,  and  may  in  time  produce  symptoms  of  intol- 
erance or  even  of  poisoning.  In  giving  drugs  to  patients 
with  dropsy,  nurses  must  be  especially  on  the  watch  for 
symptoms  of  overdosing.  The  reason  is  that  some  of  the 
drug  is  apt  to  stay  suspended  in  the  excess  of  fluid;  as 
the  dropsy  subsides,  the  drug  is  liberated  and  absorbed  by 
the  system,  sometimes  in  poisonous  quantities. 

Time  Required  for  Effect. — The  time  necessary  for  a 
drug  to  produce  its  effect  varies  with  the  individual  drug 
and  with  the  method  of  administration.  The  most 
rapid  method  is,  generally  speaking,  hypodermic  injec- 
tion, and  the  slowest,  inunction.  Rectal  absorption  is 
slower  than  absorption  from  the  stomach,  and  either 
vary  with  the  form  of  the  preparation.  A  fluid  prepara- 
tion of  a  drug  is  more  quickly  absorbed  than  a  solid  prepa- 
ration, such  as  a  powder,  pill,  or  tablet.  The  effects  of 
inhalation  are  rapid,  but  vary  again  with  the  drug  em- 
ployed. Thus,  for  example,  the  inhalation  of  nitrite  of 


TIME   OF  ADMINISTRATION   OF   DRUGS  345 

amyl  produces  results  in  less  than  one  minute,  while  for 
ether  or  chloroform  a  considerably  longer  time  is  required. 
In  giving  a  drug  by  the  stomach  a  time  must  be  chosen 
to  fit  the  cause  for  which  the  drug  is  given. 

TIME  OF  ADMINISTRATION  OF  DRUGS 

As  a  general  rule,  the  best  time  for  administering  a 
drug  is  between  meals,  when  the  stomach  is  at  rest. 
There  are,  however,  several  exceptions  to  this  rule. 

Stomachics,  which  are  given  to  improve  the  tone  of  the 
stomach  and  to  increase  the  appetite  by  stimulating  the 
secretion  of  the  gastric  juice,  should  be  given  ten  or 
fifteen  minutes  before  a  meal.  Such  are  bitters,  the  dilute 
acids  or  alkaline  tonics,  and  nux  vomica. 

Digestives,  on  the  other  hand,  are  given  from  fifteen 
minutes  to  half  an  hour  after  food.  Their  function  is 
to  supply  a  deficiency  of  one  of  the  natural  secretions 
during  digestion,  to  counteract  overacidity,  or  to  correct 
alkalinity.  The  dilute  acids  and  the  alkaline  tonics  are 
also  used  as  digestives,  and  the  official  preparations  of 
pepsin,  lactic  acid,  pancreatin,  and  others.  Pancreatin, 
being  an  intestinal  digestive  fluid,  is  given  toward  the  end 
of  gastric  digestion,  the  time  varying  with  the  kind  of 
meal  taken. 

Alcohol,  in  moderate  doses,  increases  the  appetite  if 
taken  shortly  before  meals,  and  is  of  some  value  as  a 
digestive  if  taken  with  a  meal. 

A  drug  that  is  to  act  locally  on  the  stomach  is  given  when 
the  stomach  is  most  at  rest  • — about  an  hour  before  nour- 
ishment. Nitrate  of  silver,  for  the  treatment  of  gastric 
ulcer,  is  given  in  this  way. 

Narcotics  are  given  at  the  hour  of  sleep  if  acting  quickly 
(Ex.:  morphin).  The  nurse  must  be  careful  that  every- 
thing that  is  to  l)e  done  for  or  about  the  patient  is  fin- 
ished before  the  dose  is  given,  so  that  nothing  may  inter- 
fere with  the  desired  effect.  Many  narcotics,  however, 
in  general  use  take  some  hours  to  act,  and  must,  there- 
fore, be  given  a  corresponding  length  of  time  before  the 
hour  of  sleep  (Ex.:  sulphonal,  trional). 


346  MEDICINES 

Laxatives  and  cathartics  act  most  quickly  if  the  stom- 
ach is  empty,  and  are,  therefore,  best  given  in  the  early 
morning,  before  food  is  taken.  For  convenience,  they  are 
frequently  given  at  bedtime. 

Drugs  which  have  an  irritating  effect  on  the  tissues  are 
best  taken  on  a  full"  stomach,  not  more  than  half  an  hour 
after  meals.  Such  are  iron,  arsenic,  mercury,  and  the  iodid 
preparations.  For  the  same  reason,  if  bromid  is  to  be 
taken  over  a  length  of  time,  it  should  be  given  after 
meals. 

General  tonics  with  nourishing  properties,  such  as  cod- 
liver  oil,  malt  extracts,  etc.,  are  also  best  borne  after  meals. 

RELATIVE    VALUES    OF    DIFFERENT    FORMS    OF  PREPA- 
RATIONS 

Pupils  should  be  taught  to  recognize  the  relative  values 
of  the  different  forms  in  which  drugs  are  made  up  into 
medicines.  The  value  depends  on  the  percentage  of  the 
drug  which  a  given  quantity  of  the  preparation  repre- 
sents. Thus  one  dram  of  an  infusion  presents  a  very 
much  smaller  percentage  of  a  drug  than  one  dram  of  the 
tincture  of  the  same  drug.  Pupils  should  also  be  familiar 
with  the  average  dose  of  the  preparations  they  will  be 
required  to  handle. 

Tinctures  (average  strength,  10  to  15  per  cent.,  except 
aconite,  35  per  cent.,  and  nux  vomica,  2  per  cent.). 
Average  dose,  5  to  20  minims.  Exceptions:  Tinctures  of 
aconite,  iodin,  veratrum  viride,  each,  1  to  3  minims. 

Infusions. — Average  dose,  4  drams  to  1  ounce.  Excep- 
tion: Infusion  of  digitalis,  1  to  4  drams. 

Spirits. — Average  dose,  30  minims  to  1  dram.  Excep- 
tions: Spirit  of  glonoin,  1  to  3  minims,  and  spirit  of 
phosphorus,  camphor,  and  turpentine,  3  to  10  minims. 

Aquae. — Average  dose,  4  drams  to  1  ounce.  Exception: 
Aqua  ammonia,  5  to  20  minims,  well  diluted.  It  is  not 
usually  ordered  internally. 

Syrups. — Average  dose,  1  to  2  drams.  Exception: 
Syrup  of  iodid  of  iron,  10  to  30  minims. 

Fluidextracts. — Average  dose,  10  to  30  minims.  Ex- 
ception: Fluidextract  of  cascara  sagrada,  \  to  1  dram. 


ABBREVIATIONS 


347 


(Fluidextracts  of  powerful  drugs  are  given  in  doses  of  1  to 
2  minims;  they  are  not  found  in  the  ward  medicine  chest. 
Solid  extracts  also  (i  to  1  gr.)  are  measured  in  the  dispen- 
sary, and  usually  combined  with  other  drugs  in  pill  form.) 

Mixtures. — Average  dose,  1  to  4  drams.  Exception: 
Mixture  of  asafetida,  |  to  1  ounce. 

Dilute  Acids  (strength,  10  per  cent.). — Average  dose, 
10  to  30  minims.  Exception:  Dilute  hydrocyanic  acid 
(prussic  acid,  strength,  2  per  cent.),  1  to  3  minims.1 


ABBREVIATIONS 

In    ordering    medicines    and    other    remedies,    many 
abbreviations  are  used,  with  which  nurses  must  be  familiar. 
The  following  are  the  most  common: 


Abbreviation. 
aa 

A.  C. 
Add. 

Add.  part.  dol. 

Ad  lib. 

Alt.  die. 

Alt.  hor. 

Alt.  noct. 

Aq. 

Aq.  dest. 

B.  i.  d. 
C. 

Cap. 
Cochl. 
Cochl.  mag. 
Cochl  mcd. 
Cochl.  parv. 
Collyr. 
Comp. 
Conf. 
Contin. 
Coq. 

Cras  mane 

Cras  nocte 

Cyath. 

D.  D. 

Dil. 

Dim. 

D.  in  p.  seq. 

Div. 


Latin. 
ana 

ante  cibum 
adde 

adde  partem  dolente 
ad  libitum 
alternis  diebus 
alternis  horis 
alternis  noctea 
aqua 

_aqua  destillata 
bis  in  die 
cum 
capiat 
cochleare 

cochleare  magnum 
cochleare  medium 
cochleare  parvum 
collyrium 
compositum 
confectio 
continuatur 
coque 
eras  mane 
eras  nocte 
cyathus 
detur  ad 
dilutus 
dimidius 
dividatur  in  partes 

sequales 
dividatus 


English. 

of  each  (i.  e.,  equal  parts), 
before  food, 
add  to. 

to  the  painful  spot, 
according  to  pleasure, 
alternate  days, 
alternate  hours, 
alternate  nights, 
water. 

distilled  water, 
twice  a  day. 
with. 

let  him  take. 
spoonful, 
tablespoon, 
dessertspoon, 
teaspoon, 
eye-wash, 
compound, 
confection, 
let  it  be  continued, 
boil. 

to-morrow  morning, 
to-morrow  night, 
a  glassful 
let  it  be  given  to. 
diluted, 
one-half, 
divide  in  equal  parts. 

divide. 


Chiefly  from  Dock's  "  Materia  Medica  for  Nurses." 


MEDICINES 


Abbreviation. 

Latin. 

English. 

Dur.  dolor. 

durante  dolore 

while  tbe  pain  lasts. 

Ejusd. 

ejusdem 

of  the  same. 

Empl. 

emplastrum 

plaster. 

F. 

Fahrenheit. 

Fl. 

fluidum 

fluid. 

Fol. 

folia 

leaves. 

Ft. 

fiat 

let  there  be  made. 

Garg. 

gargarisma 

a  gargle. 

H.  d. 

bora  decubitus 

at  bedtime. 

U.s. 

bora  somni 

at  sleeping  time. 

Inf. 

infusum 

infusion. 

Lin. 

linimentum 

liniment. 

Liq. 

liquor 

liquid,  a  solution. 

Lot. 

lotio 

lotion. 

M. 

misce 

mix. 

Mist. 

mistura 

mixture. 

N.  b. 

nota  bene 

note  well. 

No. 

numero 

number. 

Noc. 

nocte 

night. 

01. 

oleum 

oil. 

O.  m. 

omni  mane 

every  morning. 

Omn. 

omni 

every. 

Ov. 

ovum 

egg- 

Part.  vie. 

partibus  vicibus 

in  divided  doses. 

P.  c. 

post  cibum 

after  a  meal. 

Pil. 

pilula 

pill. 

Ppt. 

precipitate. 

L     *" 

P.  r.  n. 

pro  re  nata 

when  required. 

Pulv. 

pulvis 

powder. 

Q.  d.,  or  q.  i.  d. 

quater  in  die 

four  times  daily. 

Qq.  hor. 

quaque  bora 

every  hour. 

Q.  s. 

quantum  sufficit 

sufficient  quantity. 

Quotid. 

quotidie 

daily. 

9 

recipe 

take. 

Rad. 

radix 

root. 

Rect. 

rectificus 

rectified. 

Sat, 

saturated. 

S.  fr. 

spiritus  frumenti 

whisky. 

Sig. 

signa 

let  it  be  written  down. 

Sinap. 

sinapis 

mustard. 

Sine 

sine 

without. 

Sol. 

solution. 

S.  O.  8. 

si  opud  sit 

if  necessary. 

Sp. 

spiritus 

spirit. 

So.  gr. 

specific  gravity. 

~t-"  &* 
Stat. 

statim 

immediately. 

Sum. 

sumendum 

let  it  be  taken. 

S.  v.  g. 

spiritus  vini  gallioi 

brandy. 

Syr. 

syrupus 

syrup. 

T.  d  ,  t   i  d. 

ter  in  die 

thrice  dailv. 

T.  d.  s. 

ter  in  die  sumendum 

let  it  be  taken  thrice  daily. 

Tinct,,  tr. 

tinctura 

tincture. 

Troch. 

trochiscum 

lozenge. 

Ung. 

unguentum 

ointment. 

FAMILIAR    PREPARATIONS 


349 


Abbreviation. 
Ut  diet. 
Ves. 
Vesic. 
Vin. 


Latin. 
ut  dictum 
vesiea 
vesicular 
vinum 


English. 
as  directed, 
the  bladder, 
a  blister, 
wine. 


FAMILIAR  PREPARATIONS 

A  nurse  should  also  be  familiar  with  the  composition 
of  commonly  used  medicines  and  medicinal  preparations, 
known  under  popular  names: 


Name. 
Basham's  mixture. 


Brown  mixture. 


Calomel. 
Cream  of  tartar. 
Dover's  powder. 


Elixir  iron,  quinin, 
and  strychnin. 

Fellow's  syrup  (un- 
official). 


Fowler's  solution. 


Gray  powder. 
Gregory  powder. 
Hoffman's  anodyne. 


Laudanum. 
Magendie's  solution 

(not  official). 
Mindererus,  spirits  of, 

Muriatic  acid. 
Paregoric. 


Composition.  Dose. 

Tincture  of  the  chlorid  of  iron,     BSS-J, 

dilute  acetic  acid,  solution         diluted. 

of     acetate     of     ammonia, 

with  elixir  of  orange,  gly- 
cerin, and  water. 
Compound    licorice    mixture.     5j~5ss 

Licorice,  paregoric,  wine  of 

antimony,  spirits  of  nitrous 

ether. 

Mild  chlorid  of  mercury.  gr.  j-v 

Potassium  bit  art  rate.  gr.  xxx-oij 

Compound     opium     powder,     gr.  v-x 

Opium,    1    grain,    ipecacu- 
anha,   1    grain,    sugar    of 

milk,  8  grains. 
Syrup    of    the    phosphate   of     5  j~ij>  diluted. 

iron,  quinin,  and  strychnin. 
Syrup  of  the  hype-phosphites,     TTjxxx-Sj 

i.  e.,  of  iron,  quinin,  strych- 
nin,   calcium,    manganese, 

and  potassium. 
Liquor    potassii    arsenitis:    5     Trgj-x,  diluted. 

minims  represents  J-%  grain 

of  arsenic. 

Mercury  with  chalk.  gr.  j-v 

Compound  rhubarb  powder.       gr.  xv-5j 
Compound    spirits    of    ether:     Sj-ijj   m  ice~ 

ether,  alcohol,  and  ethereal         cold  water. 

oil. 

Tincture  of  opium.  njv-xx (adult). 

A   solution    of   morphin    sul-     TTJJX  =  gr.  J  of 

phate,  2  grains  to  1  dram.         morphin. 
Liquor  of  the  acetate  of  am-     5j-iv,         di- 

monia.  luted. 

Hydrochloric  acid  (dilute  only     nj)v-xx,        di- 

used).  luted. 

Camphorated      tincture      of     3ss-j  (adult). 

opium.     Opium,  2  grains  in 

1  ounce,  with  camphor,  ben- 

zoic  acid,  and  oil  of  anise. 


350 


MKDIL'INES 


Pills 


A.  B.  and  S. 

Blaud's. 

Blue. 


Lady  Webster. 
Plummer's. 


Prussic  acid. 


Salts 


f  Epsom. 
Glauber's. 
Rochelle. 


Seidlitz. 


Tartar  emetic. 
Tully's  powder. 


Wine  of  antimony. 


Blue  stone. 
Carron  oil. 
Friar's  balsam. 
Goulard's  extract. 
Labarraque's     solu* 

tion. 

Lunar  caustic. 
Monsell's  solution. 
Phenol. 

f  Black. 

Washes  J  Yellow' 
Red. 


Aloes,  belladonna,  cascara, 
strychnin. 

Iron  and  carbonate  of  potas- 
sium. 

Blue  mass,  mercury  with  lic- 
orice, etc.,  pill,  3  to  5  grains 
of  the  mass  equalling  J  grain 
of  mercury. 

Aloes  and  mastic. 

Compound  pill  of  antimony,  \ 
grain,  jalap,  1  grain,  and 
calomel,  \  grain. 

Hydrocyanic  acid  (dilute  only 
used). 

Sulphate  of  magnesia. 

Sulphate  of  soda. 

Potassium  and  sodium  tar- 
trate. 

f  Sodium  bicarb- 
onate, 40  gr. 

Blue  packet  ^  Rochelle    Jg, 

[     2  dr. 

White  packet,  tartaric  acid, 
25  gr. 


Pil.  j-ij 
Pil.  j-iij 

Pil.  j-ij 


Pil.  j-ij 
Pil.  j-ij 

ttEJ-ij,  diluted. 

3ij-5i 
3J-5J 


The  packets 
are  dis- 
solved sepa- 
rately, then 
poured  to- 
gether, and 
taken  effer- 
vescing. 

As  an  emetic, 
gr.  ss. 

gr.  x  =  £  of 
morphin. 

TTJJV-388 


Antimony  and  potassium  tar- 
trate. 

Morphin  sulphate,  1  grain  to 
1  dram  with  camphor,  lic- 
orice, and  carbonate  of  lime. 

Contains  tartar  emetic,  2 
grains  to  the  ounce. 

For  External  Use 

Sulphate  of  copper  (solid). 

Lime-water  and  olive  oil,  equal  parts  of  each. 

Compound  tincture  of  benzoin. 

Solution  of  the  acetate  of  lead. 

Liquor   sodae    chlorinatae,   sodium    carbonate 

and  chlorinated  lime. 
Nitrate  of  silver  stick. 
Solution  of  subsulphate  of  iron. 
Carbolic  acid. 

Calomel,  1  dram,  to  lime-water,  1  pint. 
Bichlorid  of  mercury   (corrosive  sublimate), 

A  dram,  to  lime-water,  1  pint. 
Sulphate  of  zinc,  2  grains,  to  water,  1  ounce, 

colored  with  tincture  of  lavender. 


ADMINISTRATION   OF  DRUGS 

Drugs  may  be  administered  for  either  their  general 
action  on  the  system  or  for  a  local  action  on  one  part  of 


ADMINISTRATION   OF  DRUGS  351 

the  system.  Commonly,  a  drug  taken  into  the  system 
acts  in  two  ways,  direct  or  near,  and  indirect  or 
remote. 

Drugs  are  absorbed  into  the  system  through  the  fol- 
lowing channels: 

1.  The  alimentary  canal  (the  mouth  and  rectum). 

2.  The  respiratory  system  (inhalation). 

3.  The  lymphatic  system  (hypodermic  injection). 

4.  The  arterial  system  (intravenous  injection). 

5.  The  surface  of  the  skin  (inunction  and  fumigation). 
Drugs  are  also  applied  externally  for  their  local  effect, 

as  anodynes,  counterirritants,  etc.  (See  Local  Applica- 
tion, Chap.  XL) 

Administration  by  mouth  is  the  common  method,  and 
is  that  understood  when  the  dose  of  a  drug  is  stated 
without  qualification. 

Medicines,  except  oily  preparations,  are  diluted  with 
water  unless  ordered  to  the  contrary.  Sufficient  water  to 
make  the  medicine  palatable  and  no  more  is  the  usual 
indication.  Minerals  and  other  drugs  irritating  to  the 
tissues  should  be  well  diluted,  especially  the  preparations 
of  iron,  arsenic,  and  the  dilute  acids. 

Pills,  tabloids,  and  capsules  should  be  swallowed  with 
water  to  help  in  dissolving  them.  If  not  perfectly  fresh, 
pills  and  tabloids  are  better  crushed  and  mixed  with 
water  before  administering.  Powders  should  be  dis- 
solved in  water  before  giving.  The  few  official  prepara- 
tions that  are  insoluble  in  water  may  be  floated  on  the  top 
of  a  spoonful  of  water,  or  taken  directly  on  the  tongue 
and  swallowed  with  water.  Unpalatable  powders  may 
be  mixed  with  syrup,  jams,  or  honey.  Salts  of  mineral 
waters  are  taken  well  diluted,  and  are  more  efficacious 
if  taken  in  warm  water.  An  exception,  however,  is  made 
in  administering  salts  by  the  Matthew  Hay  method  to 
dispel  dropsy.  Salts  are  then  given  in  concentrated  doses. 

To  make  an  oil  palatable  it  may  be  given  with  orange 
wine,  sherry,  or  brandy,  or  the  oil  may  be  shaken  into  an 
emulsion  with  double  the  quantity  of  hot  milk  or  black 
coffee.  To  suck  a  slice  of  lemon  before  and  after  a  dose 
of  castor  oil  will  generally  take  away  the  taste.  A  piece 


352 


ME  I)  1C  INKS 


of  ice  sucked  just  before  taking  a  dose  will  minimize  a  dis- 
agreeable flavor. 

Certain  drugs  are  liable  to  discolor  or  otherwise  injure 
the  enamel  of  the  teeth,  and  should  be  invariably  taken 
through  a  glass  drinking  tube.  The  special  drugs  to  be 
guarded  against  are  iron  in  all  fluid  forms,  the  iodids,  and 
the  dilute  acids. 

The  ward  medicine  chest  contains  glass  measures, 
graduated  by  drams  to  2  ounces,  minim  measures  for  doses 
under  one  dram,  pipets  for  measuring  doses  ordered  by 
drops,  or  guttce,  and  not  by  minims,  and  glass  tubes  through 
which  such  drugs,  etc.,  that  discolor  or  corrode  the  teeth 
should  be  taken.  Separate  glasses  should  be  kept  for 
oily  mixtures. 

The  time-honored  rule  of  reading  the  label  on  a  bottle 
three  times  should  be  practised  until  it  becomes  a  habit. 
The  rule  is  to  read  the  label  on  taking  the  bottle  from  its 
place,  before  pouring  the  medicine,  and  again  on  replac- 
ing the  bottle.  In  pouring,  the  bottles  should  be  held 
with  the  label  uppermost  to  avoid  soiling  the  label  with 
drippings.  In  measuring,  the  graduate  is  held  so  that 
the  eye  is  on  a  level  with  the  line  marking  the  quantity. 

Different  colors  denote  the  different  hours  at  which 
medicines  are  to  be  given,  thus:  Red,  four-hourly, 
red  with  some  additional  mark,  such  as  a  corner  cut  off, 
two-hourly;  blue,  six-hourly,  and  blue  with  a  corner  off, 
three-hourly;  yellow  before  food,  orange  after  food,  green 
three  times  a  day,  and  plain  white  cards  for  special  orders. 
On  the  card  is  written  the  patient's  name,  the  hour,  the 
medicine,  and  dose,  thus: 


WARD  A. 
12.         4.         8. 

John  Smith, 


Tinct.  digitalis, 
10  minims  in  water. 


ADMINISTRATION   OF  DRUGS  353 

In  ward  nursing  care  is  necessary  to  prevent  a  dose 
being  given  to  the  wrong  patient.  Most  hospitals  have 
some  rule  or  method  to  lessen  the  risk  of  such  occur- 
rences. The  colored  card  system  is  probably  the  most 
widely  used. 

The  cards  are  written  out  by  the  head  nurse  from  the 
order-book  or  head-board,  and  are  kept  in  separate  packets 
in  the  medicine  closet.  At  the  hour  the  nurse  places  the 
cards  in  a  row  in  front  of  her,  measures  out  each  medicine, 
and  covers  the  glass  with  the  card,  which  is  not  removed 
until  the  medicine  reaches  the  patient.  The  packet  of 
cards  is  then  placed  on  the  head  nurse's  table,  as  an  indica- 
tion that  the  medicines  have  been  given.  The  head  nurse 
should  keep  a  memorandum  of  the  number  there  should  be 
in  each  packet,  so  that  she  can  tell  at  once  if  any  have  been 
forgotten.  When  a  medicine  is  discontinued,  the  head 
nurse  tears  up  the  card.  This  system  also  saves  the  daily 
writing  out  of  long  lists  of  medicines  to  be  given,  a  con- 
siderable item  in  a  large  ward. 

It  is  important  that  medicines  should  be  given  at  the 
hour  at  which  they  are  ordered.  If  a  dose  for  any  reason 
is  omitted,  a  note  in  writing  should  be  made  of  the  fact, 
stating  the  reason.  When  a  dose  has  been  omitted,  the 
omission  cannot  be  rectified  by  giving  a  larger  dose  at 
the  next  time. 

By  Rectum. — Administration  by  rectum  is  employed 
when,  for  general  or  local  causes,  feeding  by  the  stomach 
is  not  possible:  for  example,  in  persistent  vomiting,  gastric 
ulcer,  stricture  of  the  esophagus,  in  some  operations  on 
the  mouth  or  on  parts  of  the  alimentary  canal,  and  occa- 
sionally in  conditions  of  coma  and  delirium.  Drugs  are 
also  given  by  rectum  to  apply  local  remedies  or  to  relieve 
local  conditions,  such  as  constipation,  tympanites,  or 
diarrhea.  The  absorptive  power  of  the  rectum  is  less  than 
that  of  the  stomach;  in  consequence,  the  dose  by  rectum 
is  usually  twice  that  given  by  mouth,  unless  the  drug  is  ex- 
ceptionally powerful. 

Drugs  are  given  by  rectum,  by  enema,  by  douche,  or 
by  suppository,  the  patient  lying  with  the  legs  flexed  either 
in  the  dorsal  position  or  on  the  left  side.  (See  Enemata.) 

23 


354  MEDICINES 

HYPODERMIC   INJECTION 

Drugs  are  given  by  hypodermic  injection  when  imme- 
diate action  is  required,  or  in  place  of  rectal  administra- 
tion, when  giving  by  mouth  is  impracticable  for  the  reasons 
just  stated.  The  drug  is  taken  without  alteration  di- 
rectly into  the  circulation  by  the  lymphatic  vessels :  for  this 
reason  the  dose  is  usually  half  the  quantity  given  by  mouth. 

Concentrated  solutions  of  the  active  principle  of  a  drug 
are  used  for  hypodermic  injection.  For  this  purpose  the 
drug  is  usually  put  up  in  the  form  of  small  tabloids,  readily 
dissolved  in  a  few  minims  of  water.  Stimulants,  such  as 
brandy  and  ether,  are  given  by  hypodermic  undiluted, 
and  camphor  in  two  or  three  drops  of  sweet  oil. 

Hypodermic  injections  are  given  in  two  ways,  super- 
ficially, i.  e.,  directly  under  the  skin,  or  deep,  into  the  mus- 
cular tissue.  The  rule  used  to  stand  that  drugs  irritating 
to  the  tissues  were  given  deep  into  a  muscle,  and  those 
without  irritating  properties,  by  the  superficial  method. 
At  the  present  day  the  deep  method  is  in  favor  for  all 
drugs  with  the  exception,  perhaps,  of  morphin,  atropin, 
and  strychnin,  which,  for  convenience  sake,  are  frequently 
given  in  the  fleshy  part  of  the  upper  arm.  Drugs  in  com- 
mon use  that  are  specially  irritating  to  the  tissues  are 
ergotin,  digitalin,  mercury,  arsenic,  and  camphor. 

Certain  drugs  are  administered  by  hypodermic  injec- 
tion to  act  as  local  anesthetics  during  operations  or  painful 
surgical  procedures.  Cocain,  eucain,  and  a  preparation 
of  cocain  containing  morphin,  known  as  Schleich's  solu- 
tion, are  the  usual  anesthetics  employed.  A  long  hypo- 
dermic needle  is  chosen,  and  introduced  immediately 
under  the  skin  or  mucous  membrane,  below  the  line  of  the 
proposed  incision;  the  needle  is  withdrawn  a  little  at  a 
time,  and  a  few  drops  of  the  solution  injected  at  each  stop. 
The  injection  should  be  completed  five  minutes  before  the 
operation. 

Cocain  is  used  for  this  purpose  in  the  strength  of  0.5 
to  1  per  cent,  in  sterile  distilled  water.  From  1  to  2  grains 
is  the  usual  dose.  Schleich's  solution,  of  which  there  are 
three  formulas,  is  given  in  a  larger  quantity  of  fluid,  suffi- 
cient to  produce  edema  of  the  part. 


HYPODERMIC   INJECTION 


355 


Drugs  for  Hypodermic  Injections. — The  following  is  a 
table  of  the  drugs  most  commonly  given  by  hypodermic: 


OSia 

o  '    ^ 
p 
g 

IHhj 

15s 

2.8? 

3X! 

cr5' 

O 

o 
o 

S. 
5' 

tr 

<<• 

g 

4 
•-^ 
n 
o 

j  Strychnin 

Apomorph 

>§ 
So 

>§£ 

| 

C  CD 

o 

'Is" 

o  a. 

°"o 
i-S    O 

&• 

3 

O 

i-! 

r" 

09 

-3" 

5- 
P 

b" 

x 
& 

£-2 

II 

ct-  P 

fD    & 

O 

td 

p 

O   & 

O 

i-! 

•    a 

§  f* 

2. 

p" 

0 

5  s" 

o- 

0 

h-«  O 

°-n. 
'  P- 

CT1 

s. 

Cu 

1:1 

1 

CR  CR 

r*  r* 

? 

era 

eg 

"*9 

<5<Q 

> 

H 

X 
X 

X 

Mj      Q^M 

at- 

of— 

01 

1 

^S^ 
S»ss 

shj 

K 

a 

o 

H 

or 

O    Ei"lT3 

oi, 

K 

0) 

o  3  jj 

o| 

oi 

Ki 

"Sg, 

U 
o 

Si 

i 

^5- 

t>t> 

> 

>; 

hd 

>> 

??£? 
S-E- 

7? 

£- 

E- 

0   CT3 

E^l 

^v? 
gLfL 

s'.sl 

o* 

c 

O    c*1  ^ 

S.Cf? 

cTo 

51  S^ 

£ 

^sa 

£&; 

d 

K 

2,2, 

8. 

c 

S.I.H- 

o  o 

2 

tj*.-. 

'^S- 

8 

o 

s 

% 

P-g'l 

cro 
2-1"53. 

H 

en  o 

p 

O    - 

s*£ 

O 

5  § 

<) 

£3 

&.B 

X 

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H 

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3 

c  •"' 

00 

n 
p 

*-s   ^ 

O   S* 

r 

goo 

.CB   t,.  rc   CD  "w 

^3330 
•£.  2  o  o  33 

p   0 

3.5 

S' 

O 

C   P 
y;    *~i 

O    &- 

o 

^3  ?°  5 
f:  %  g 

s  &s 

i 

h3 

cc  5-0 

o  S  ^ 
a  <!  ro 

^r 

*3>    '• 

o  p 

^  g 

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3  |-3 

3  —  < 

n 

EL 

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P   S, 

,°  c 

s 

CD 

a*i 

w.  n 

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o 

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P 

11   ff 

stimulant, 
it,  especia' 

33    C            ^H-S            o 

^.  •—  '  p   Qj  O         ao         to 

l|^fi-f|^|- 

sr^      erg  M  c  CL.C 

111  ill  ill 

respirator} 

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p      3  ^ 

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P  w                  0 

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o 

>-! 
X 

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S.|BTO- 

£'3~s  ?i 

•       M    ""S    i-*    -^3 
S-  «    0    ffl 

Ifll 

3   K.-T3   ^ 

V. 

-"     O              O 

c*                *1 

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*0                   « 
ft)                   w 
O 

s* 

rt> 

on 

S.-, 

hi 

if 

ee 

~. 
^ 

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.T1                rt 

i-*i  ^D 

ra 

CD 

3s' 

^                      O 

3 

g 

?^ 

H 

»-S*a 

r& 

•i 

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5'  s: 

?  o^ 

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CO 

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1 

O>    03 

c» 

350 


MEDICINES 


Antitoxin  Serums. — (See  Chapter  XIV.) 
Hypodermoclysis. — (See  Chapter  XIV.) 
Lumbar  Injections. — (See  Chapter  XIV.) 
Intravenous  Injections. — (See  Chapter  XIV.) 
On  the  continent  of  Europe  it  is  quite  customary  to 
give  almost  all  drugs,  including  even  irritants,  such  as  iron, 
arsenic,  and  digitalis,  by  hypodermic  or  "  piqure,"  in  pref- 
erence to  by  mouth.     The  drugs  are  put  up  each  separate 
dose  in  a  tiny  glass  vial,  hermetically  sealed,  and  opened 
by  breaking  off  the  slender  neck:  the  needle  is  attached 
directly  to  the  neck  by  a  small  piece  of  rubber  tubing. 

There  are  two  preparations  of  digitalis  in  use  for  hypo- 
dermic injection — an  American  preparation,  digitsdine, 
of  which  the  dose  is  -^  to  -£$  grain,  and  a  German  prepara- 
tion, digita/m,  of  which  the  dose  is  y1^  to  -£  grain.  Since 


Fig.  129. — Hypodermic  tray. 

the  difference  of  the  dose  is  so  great,  it  is  highly  important 
to  be  certain  which  preparation  is  being  used. 

To  give  a  hypodermic  injection  it  is  necessary  to  prick 
the  surface  of  the  skin,  thus  opening  what  may  prove  a 
channel  of  infection  if  proper  precautions  are  not  ob- 
served. The  hands  of  the  operator  and  the  area  to  be 
pricked  must  be  surgically  clean,  the  syringe,  needle,  and 
injection  sterile  (Chap.  XIV).  At  the  same  time  it  is 
important  that  the  technic  employed  should  be  simple 
and  take  up  no  unnecessary  time.  A  small  tray  arranged 
with  all  necessary  articles  for  the  operation  should  form 
part  of  the  equipment  of  the  medicine  cupboard.  This 
consists  of  an  alcohol  lamp,  a  spoon,  the  syringe,  a  bottle 
of  alcohol,  a  small  covered  jar  for  sterile  gauze  sponges, 


HYPODERMIC   INJECTION 


357 


another  for  needles,  a  small  glass  or  gallipot,  matches,  the 
tabloids  of  the  drugs  used  in  small  stoppered  bottles  or 
glass  tubes.  The  needles  may  be  kept  in  shot,  emery 
powder,  or  between  layers  of  gauze,  and  should  invariably 
be  kept  threaded  with  wire  when  not  in  use,  the  wire 
coming  well  beyond  the  point.  If  the  syringe  is  entirely 
of  glass,  with  solid  glass  piston,  it  is  sterilized  by  boiling. 


Fig.  130. — Ordinary  glass  and  metal  hypodermic  syringe  (Morrow). 


The  syringe  in  general  use  has  rubber  washers,  which  are 
injured  by  boiling;  it  is  best  prepared  by  soaking  in  alcohol 
before  use.  Proceed  as  follows: 

1.  Fill  the  syringe  with  alcohol;  pour  some  into  the 
gallipot,  and  leave  the  syringe  to  soak  for  a  few  minutes. 

2.  Wash  your  hands. 

3.  Boil  the  needle  over  the  alcohol  lamp  in  the  spoon 
without  the  wire. 


Fig.  131. — Method  of  giving  a  hypodermic  injection  (Thornton). 

4.  Empty  the  syringe  and  draw  up  about  five  minims 
of  the  boiled  water. 

5.  Unscrew    the   top    and    shake  in  from  the  vial  a 
tabloid  of  the  required  dose;  it  will  dissolve  readily.     A 
drug  should  never  be  boiled. 

6.  Take  the  needle  with  a  sterile  gauze  sponge  and  join 
to  the  syringe.     Keep  the  sponge  round  the  needle  until 
actually  to  be  used. 


358  MEDICINES 

7.  Hold  the  syringe  upright,  and  press  the  piston  gently 
until  a  drop  appears  at  the  point.    This  is  to  expel  the  air. 

8.  Soak  a  gauze  sponge  in  alcohol,  carry  it  and  the 
syringe  to  the  patient.     The  alcohol  sponge  is  to  cleanse 
the  site  of  the  puncture.     It  should  be  rubbed  briskly 
over  the  surface  until  the  skin  is  well  reddened;    this 
removes  superficial  grease  and  epithelium  from  the  area, 
and  the  increased  blood-supply  brought  to  the  surface 
promotes  quick  absorption  of  the  drug. 

In  giving  a  hypodermic  superficially,  the  usual  site  is 
the  fleshy  part  of  the  upper  arm.  A  piece  of  flesh  is 
pinched  between  the  finger  and  thumb  and  the  needle 
introduced  in  a  slanting  direction.  In  giving  the  injec- 
tion deep,  the  muscles  of  the  buttock  or  the  thigh  are 
generally  chosen,  though  the  muscles  of  the  chest  and 
abdomen  may  equally  well  be  used.  The  skin  is  stretched 
tightly  over  the  part  and  the  needle  plunged  straight  into 
the  tissues.  Care  must  be  taken  that  the  puncture  is 
not  made  over  a  superficial  vein  or  too  near  a  bone,  or  the 
periosteum  may  be  injured.  The  needle  is  inserted 
nearly  to  its  full  length  and  then  withdrawn  slightly 
while  the  injection  is  made.  The  injection  is  given  gently. 
As  the  needle  is  withdrawn  the  gauze  sponge  is  pressed 
over  the  puncture  and  held  in  place  a  few  moments. 
A  few  moments'  light  massage  round  (not  over)  the  site 
of  puncture  will  hasten  the  absorption  of  the  drug. 

Care  must  be  taken  to  use  a  sharp  needle :  a  blunt  one 
causes  unnecessary  pain.  Careless  technic  may  result 
in  the  infection  of  the  part  and  the  formation  of  an  abscess 
at  the  site  of  the  puncture. 

INHALATION— ANESTHESIA 

Volatile  drugs  may  be  administered  by  inhalation, 
either  for  general  or  for  local  effects. 

The  general  systemic  effects  obtained  by  inhalation  are : 

1.  General  anesthesia. 

2.  Stimulation  of  the  general  circulation. 

Anesthesia. — The  administration  of  drugs  for  the  pur- 
pose of  general  anesthesia  can  be  taught  only  by  many 
careful  demonstrations  from  an  expert  anesthetist,  fol- 


INHALATION — ANESTHESIA  359 

lowed  by  closely  supervised  practice.  Wherever  practi- 
cal it  should  be  taught;  as  emergencies  arise,  both  in 
private  nursing  and  in  the  smaller  hospitals,  where  a  nurse 
may  be  required  to  act  as  anesthetist.  Moreover,  at  the 
present  day,  both  in  hospital  work  and  in  private  practice, 
nurses  are  proving  themselves  exceedingly  reliable  as 
anesthetists,  and  several  of  the  leading  hospitals  have 
nurses  in  these  positions,  with  very  satisfactory  results. 

The  anesthetics  in  most  frequent  use  are  nitrous  oxid 
gas,  chloroform,  and  ether,  and  derivatives  from  ether, 
such  as  ethyl  chlorid,  ethyl  bromid,  and  such  patent 
preparations  as  antidolorin,  etc. 

Nitrous  oxid  gas  is  used  where  very  short  anesthesia  is 
necessary,  as  in  dentistry,  opening  an  abscess,  etc.  The 


Fig.  132. — Esmarch  chloroform-inhaler:    a,  Stockinet  cover,  to  be 
neld  tense  by  b,  wire  frame;  c,  dropping-bottle  (De  Nancrede). 

mouth  and  nose  are  covered  with  a  rubber  mask  con- 
nected by  a  tube  with  a  tank  containing  the  gas;  the  gas 
is  inhaled  directly  from  the  tank.  Consciousness  is  lost 
in  less  than  three  minutes,  and  recovered  as  quickly  when 
the  gas  is  removed.  There  are  usually  no  after-effects,  as 
in  other  forms  of  anesthesia. 

Chloroform. — Although  not  so  widely  used  as  ether, 
chloroform  is  preferred  in  some  conditions.  It  is  pleasanter 
to  take  than  ether,  recovery  is  quicker,  and  the  after- 
effects are  less  disagreeable.  It  is  not  considered  so  safe 
as  ether  on  account  of  its  depressant  effect  on  the  heart; 
on  the  other  hand,  it  is  less  irritating  to  the  respiratory 
organs  and  to  the  kidneys.  It  is  largely  used  in  obstetrics, 


360 


MEDICINES 


a  very  little  chloroform  producing  insensibility  to  pain 
without  the  muscular  relaxation  of  complete  anesthesia, 
which  would  delay  labor. 

Chloroform  is  given  on  a  special  "  mask,"  a  convex 
wire  frame,  a  convenient  size  for  fitting  over  the  mouth 
and  nose,  over  which  a  piece  of  flannel  is  stretched 
(Fig.  132).  The  mask  is  held  in  front  of  the  mouth  and 
nose,  and  the  chloroform  dropped  from  the  drop  bottle. 
The  nose  and  lips  are  smeared  with  cold  cream  or  vaselin, 
to  prevent  blistering  if  the  chloroform  should  accidentally 
come  in  contact  with  the  skin. 


Fig.  133. — The  Clover  ether  inhaler  (Morrow). 

Accidental  death  occurring  during  chloroform  anesthesia 
is  due  to  paralysis  of  the  heart;  the  pulse,  therefore,  must 
be  closely  watched. 

Ether. — Ether  is  the  anesthetic  universally  used  in 
operative  work.  It  is  unpleasant  to  take,  and  compara- 
tively slow  in  its  action;  for  this  reason  nitrous  oxid  gas 
is  often  given  as  a  preliminary.  It  is  safer  than  chloro- 
form, as  it  acts  as  a  stimulant  to  the  heart  and  respiration. 
The  after-effects  are  unpleasant,  though  considerably 
less  so  when  the  ether  is  skilfully  given.  The  common 
effects  are  nausea,  vomiting,  violent  "  swimming  "  head- 
ache, and  constipation.  Ether  is  administered  by  the 
closed  or  the  open  method. 


INHALATION — ANESTHESIA 


361 


Closed  Method. — For  the  closed  method  a  special  appa- 
ratus, known  as  the  Clover  inhaler,  is  generally  used  (Fig. 


J8 


d 


Fig.  134. — Ether  cone:  a,  Cardboard;  b,  towel  with  cardboard 
rolled  inside  from  points  1  to  2 ;  c,  long  end  of  towel  drawn  through 
the  cone;  d,  cone  complete,  with  gauze  sponge  pinned  in. 

133).     The  ether  is  contained  in  a  reservoir  (a)  connected 
with  a  large  rubber  bag  (6),  from  which  a  tube  leads  to  a 


362  MEDICINES 

rubber  face-piece  (c).  The  face-piece  is  fitted  closely  over 
the  mouth  and  the  nose,  the  patient  breathing  thus  directly 
from  the  rubber  bag.  Fresh  air  is  admitted  now  and  then 
by  removing  the  face-piece. 

The  open  method  of  giving  ether  is  to  drop  the  ether  on 
a  folded  towel,  holding  it  at  a  short  distance  from  the 
patient's  face.  This  method  is  very  slow  and  wastes 
much  of  the  ether. 

The  semi-open  method,  although  slower  than  the  closed, 
is  considered  safer,  and  generally  preferred.  The  ether 
is  dropped  on  a  piece  of  gauze  placed  at  the  apex  of  an 
open  cone,  the  base  of  which  is  held  down  over  the  patient's 
nose  and  mouth.  Various  cones  are  used  for  this  method; 
one  of  the  simplest  (Fig.  134)  is  made  as  follows:  Take  a 
piece  of  cardboard  18  inches  long  by  5^  inches  wide.  Fold 
like  a  cuff,  overlapping  6  inches,  and  shape  one  margin 
with  a  pair  of  scissors  to  fit  over  the  chin  and  nose;  the 
folded  cuff  is  12 J  inches  round.  Place  the  folded  card- 
board on  a  dressing  towel,  so  that  on  one  side  of  the  cuff 
there  are  three  or  four  inches  of  towel,  and,  on  the  other, 
half  of  the  width  of  the  towel.  Roll  up  tightly. 

Turn  the  narrow  margin  of  the  towel  inside  the  edge  of 
the  cuff. 

Push  the  wide  margin  of  the  towel  through  the  cuff, 
and  turn  down  over  the  outside.  Make  the  edge  of  the 
towel  into  a  firm  little  roll;  this  makes  a  convenient  grip 
to  hold  the  cone  in  place. 

Lay  a  large  gauze  sponge  inside  the  cuff  at  the  straight 
edge,  and  fasten  in  place  with  a  safety-pin. 

The  cone  is  held  down  firmly  over  the  nose  and  mouth, 
fitting  closely  round  the  chin;  the  ether  is  dropped  on  the 
gauze  sponge. 

Stages  of  Ether  Anesthesia. — In  administering  ether 
three  stages  are  noticed: 

First:  Primary  Anesthesia. — The  patient  is  semicon- 
scious, the  muscles  are  not  relaxed,  the  face  is  flushed, 
the  pulse  quick,  but  regular,  the  pupils  dilated,  but  react 
to  light  (the  last  condition  may  be  absent  if  morphin  has 
been  given).  Following  this  stage  is  an  intermediate 


INHALATION — ANESTHESIA  363 

stage,  in  which  the  patient  is  highly  excited,  frequently 
violent,  and  extremely  difficult  to  restrain. 

Second:  Surgical  Anesthesia. — The  patient  is  profoundly 
unconscious,  the  muscles  are  quite  relaxed,  though  never 
absolutely  (for  example,  some  spasm  is  present  in  the 
perineal  muscles),  the  pulse  is  quick  and  regular,  but  less 
quick  than  in  the  primary  stage,  the  respirations  are 
slow,  deep,  and  regular,  the  pupils  are  contracted,  but  still 
react.  It  is  during  this  stage  that  surgical  operations  are 
performed.  In  certain  conditions,  as  in  operations  on  the 
perineum,  it  may  be  necessary  to  push  the  anesthetic 
further,  but,  speaking  generally,  the  patient  is  not  allowed 
to  go  beyond  this  stage. 

It  is  important  to  bear  in  mind  that  in  giving  ether  the 
quality  of  the  breathing  is  the  most  reliable  guide  to  the 
patient's  condition:  as  long  as  the  respirations  are  slow, 
deep,  and  regular,  the  danger  stage  has  not  been  reached. 

Third:  Profound  Anesthesia. — This  stage  is  fatal  if 
continued;  the  muscles  are  absolutely  relaxed,  respira- 
tions are  rapid  and  become  quickly  shallow,  the  pulse 
is  rapid  and  may  be  irregular,  the  skin  pale  and  clammy, 
the  pupils  again  dilate  and  do  not  react.  In  a  fatal  case 
the  breathing  stops  before  the  pulse.  Hemorrhage  oc- 
curs from  the  absolute  relaxation  of  the  muscular  walls 
of  the  blood-vessels.  If  this  stage  has  been  accidentally 
reached,  the  ether  must  be  instantly  removed,  and  means 
taken  to  restore  the  patient.  The  usual  means  are  arti- 
ficial respiration,  fresh  air  or  oxygen,  and  stimulants  by 
hypodermic  injection,  especially  atropin  (y^  to  -fa  grain), 
which  is  the  most  powerful  respiratory  stimulant  known. 

An  accident  that  may  occur  in  administering  a  general 
anesthetic  is  allowing  the  tongue  to  fall  back  over  the 
glottis  and  thus  cutting  off  the  supply  of  air.  To  prevent 
this  the  head  is  kept  to  one  side  and  the  jaw  held  forward. 
A  pair  of  forceps  should  always  be  at  hand  to  pull  the 
tongue  outside  the  mouth  if  such  an  accident  happens. 

Examination  Before  Anesthetizing. — Before  an  anes- 
thetic is  given,  there  is  always  a  preliminary  examination 
of  the  heart,  the  lungs,  and  the  kidneys  (the  latter  by 
examination  of  the  urine).  Ether  is  a  local  irritant:  it 


304  MEDICINES 

produces  little  effect  on  healthy  tissue,  but  is  excessively 
irritating  to  diseased  organs.  For  this  reason  ether  as  an 
anesthetic  is  contraindicated  when  either  kidneys  or  lungs 
are  unhealthy,  and  chloroform  is  frequently  given  instead. 

Chloroform  is  depressing  to  the  heart;  it  is,  therefore, 
contraindicated  when  there  is  any  weakness  of  that 
organ.  If  chloroform  is  pushed  to  a  fatal  conclusion,  the 
pulse  fails  before  the  respirations. 

Preparations  derived  from  ether,  such  as  ethyl  chlorid 
or  ethyl  bromid,  are  also  much  in  use  as  anesthetics  for 
minor  operations,  where  muscular  relaxation  is  not  neces- 
sary, in  place  of  nitrous  oxid  gas,  and  may  also  be  preferred 
to  chloroform  in  obstetric  work.  They  are  given  by  the 
open  method,  on  a  piece  of  folded  gauze  or  a  towel. 

Local  Anesthesia. — In  cases  where  pain  is  slight  or  of 
momentary  duration,  local  anesthesia  is  used  instead  of  gen- 
eral anesthesia,  and  may,  conveniently,  be  considered  here. 

The  operation  may  be  conducted  with  the  part  im- 
mersed in  water  as  hot  as  can  be  borne;  this  is,  ob- 
viously, only  practical  in  a  limited  way,  as  in  minor 
operations  on  a  hand  or  foot.  More  commonly  the  local 
site  is  superficially  frozen  by  some  such  substance  as 
ether.  Ethyl  chlorid  and  similar  preparations  are  put  up 
in  sealed  glass  tubes,  fitted  with  a  special  metal  cap  held 
by  a  spring  over  a  very  fine  opening.  On  inverting  the 
tube  and  opening  the  cap,  a  fine  jet  of  the  preparation  is 
thrown  on  to  the  skin.  The  part  is  anesthetized  when 
the  skin  is  whitened. 

Local  Anesthesia  by  Cocain. — (See  p.  354.) 

Spinal  Anesthesia. — (See  p.  525.) 

Inhalation  for  Stimulation. — For  purposes  of  general 
stimulation  some  drugs  are  also  administered  by  inhala- 
tion. The  fumes  of  ammonia  may  be  inhaled  through  the 
nose,  causing  direct  stimulation  of  the  nerve-centers 
that  govern  the  act  of  respiration  and  the  action  of  the 
heart;  they  afford  relief  in  syncope  and  some  forms  of 
headache.  The  ordinary  smelling-salts  are  prepared  from 
ammonia,  rock-salt  crystals,  and  some  aromatic  perfume. 
Any  pungent  odor,  such  as  that  of  burnt  feathers,  may 
produce  the  same  effect. 


INHALATION — ANESTHESIA  365 

Inhalation  of  the  vapor  of  amyl  nitrite  causes  prompt 
dilatation  of  the  arteries,  thus  lowering  the  blood-pressure 
and  relieving  distressed  cardiac  conditions.  It  is  the 
common  remedy  in  attacks  of  cardiac  asthma  or  of 
angina  pectoris.  The  best  preparations  are  the  nitrite 
of  amyl  perles:  small  sealed  glass  capsules  containing 
3  minims  of  the  drug.  The  capsule  is  broken  in  a  fold  of 
gauze  or  a  handkerchief,  and  held  to  the  nostrils.  If 
placed  thus  in  a  tumbler,  and  the  tumbler  held  over  the 
mouth  and  nose,  none  of  the  fumes  are  lost. 

Inhalations  are  largely  used  for  local  action  on  some 
part  of  the  respiratory  system.  The  drugs  are  used  dry, 
aa  smoke,  or  given  in  steam. 

To  relieve  asthma  various  patent  apparatus  are  sold, 
containing  either  stramonium  or  potassium  nitrate  (salt- 
peter), in  convenient  form  for  vaporizing. 

An  economic  preparation  of  saltpeter  for  inhalation  is 
made  as  follows:  A  saturated  solution  of  the  drug  is 
made  in  boiling  water,  and  a  sheet  of  white  blotting- 
paper  placed  to  soak  in  the  solution.  When  thoroughly 
saturated,  the  blotting-paper  is  hung  up  to  dry  and  then 
cut  into  convenient  strips.  A  strip  at  a  time,  placed  on 
a  plate  and  set  alight,  will  smolder  slowly,  giving  off 
the  fumes  of  saltpeter,  soothing  the  irritated  tissue  of  the 
trachea,  and  thus  relieving  the  spasmodic  respirations. 
The  fumes  may  be  directed  toward  the  patient's  face  by 
means  of  a  cone  improvised  from  a  piece  of  stiff  paper. 
The  leaves  of  stramonium  can  be  burnt  in  the  same  way. 

Steam  inhalations  are  used  to  relieve  spasmodic  breath- 
ing, to  disinfect  bronchial  secretions,  and  to  stimulate  ex- 
pectoration. Plain  boiling  water  may  be  used,  or  the 
water  may  contain  some  drug  with  one  or  other  of  these 
properties. 

Special  closed  kettles  are  sold  for  the  purpose,  fitted  with 
u  long  straight  spout  and  a  small  opening  for  filling. 
The  steam  is  under  low  pressure,  and  is  emitted  from  the 
spout  in  a  steady  stream.  They  can  be  heated  over  an 
alcohol  lamp  or  gas-stove,  and  kept  at  steaming-point 
for  hours,  thus  carrying  on  the  treatment  without  inter- 
mission. In  place  of  adding  the  drug  to  the  boiling 


366 


MEDICINES 


water,  a  small  sea-sponge  may  be  kept  soaked  with  the 
drug  and  secured  at  the  mouth  of  the  spout.  The  drugs 
most  frequently  used  in  this  way  are  benzoin,  eucalyptus, 
and  creosote.  In  giving  an  inhalation  in  this  manner,  the 
bed  must  be  carefully  screened,  and  the  spout  of  the  kettle 
directed  inside  the  screen.  In  hospital  wards  some  ade- 
quate means  of  screening  is  always  at  hand.  Rods  of 
gas-piping  screwed  to  the  four  posts  and  connected  by 
cross  rods  at  the  top  make  a  satisfactory  frame  on  which 
cotton  curtains  can  be  hung,  one  across  the  entire  top, 


Fig.  135.— Croup  kettle  (J.  P.  C.  Griffith). 

forming  a  canopy.  The  kettle  stands  outside.  The  spout 
enters  the  curtained  space  at  the  side  of  the  bed,  and  is 
directed  toward  the  patient's  face. 

Such  a  screen  can  be  improvised  from  a  clothes-horse, 
over  which  sheets  are  securely  pinned.  The  upper 
half  of  the  bed  is  sufficient  to  inclose.  The  sheet  forming 
the  canopy  is  made  to  hang  down  in  front,  about  half  way 
to  the  mattress,  and  being  pinned  to  the  screen  on  either 
side,  a  screened  space  sufficient  for  practical  purposes  is 
formed. 


INHALATION — ANESTHESIA 


367 


Where  continuous  treatment  is  not  necessary,  the  in- 
halation may  be  given  conveniently  from  a  pitcher  or 
with  one  or  other  of  the  patent  inhalers. 

A  small  pitcher,  well  warmed,  is  half  filled  with  boiling 
water,  and  the  drug  added.  A  towel  is  then  folded  round 
the  top,  leaving  an  opening  which  is  placed  over  the  mouth 


Fig.  136. — A  movable  croup  tent  made  of  gas-piping  and  dimity 
curtains.  The  frame  is  quite  separate  from  the  bed,  which  it  en- 
tirely surrounds.  A  canopy  curtain  also  covers  the  top  when  neces- 
sary. By  substituting  black  curtains,  a  dark  cabinet  (for  eye  cases, 
etc.)  is  contrived  (Folyclinic  Hospital,  Philadelphia). 

and  nose,  and  the  patient  breathes  in  the  steam.  The 
principle  of  any  patent  inhaler  is  the  same:  the  pitcher 
is  merely  made  in  a  convenient  shape  and  fitted  with  a 
mouth-piece. 

Special  inhalations  for  the  throat  are  frequently  ordered 
merely  warm,  and  in  others  the  vapor  is  produced  by 
chemical  reaction,  and  should  not  be  heated  at  all. 


368  MEDICINES 

When  the  drug  is  required  for  local  application  to  the 
throat  or  the  posterior  nares,  the  throat  spray  is  often 
preferred  to  the  inhaler,  in  order  to  apply  the  remedy  with- 
out the  relaxation  of  the  parts  caused  by  the  steam.  In 
spraying  the  posterior  nares,  the  tip  of  the  nose  is  pushed 
upward,  and  the  spray  directed  straight  backward,  not 
up  the  nose,  as  is  generally  attempted. 

INUNCTION 

Drugs  are  absorbed  through  the  surface  of  the  skin 
by  inunction  only  in  a  limited  way.  The  drug  may  be 
blended  with  an  oil  or  an  ointment  and  rubbed  over  the 
surface  until  it  is  absorbed. 

Cod-liver  oil  or  olive  oil  is  used  as  an  inunction  for 
marasmic  infants  or  delicate  children.  The  oil  should  be 
warmed  and  the  abdomen  washed  previously  with  hot 
soap  and  water  and  dried.  The  oil  is  rubbed  into  the 
abdominal  wall  by  the  palm  of  the  hand,  using  a  circular 
movement.  Mercury  is  very  commonly  given  to  syphilitic 
patients  by  inunction.  One-half  to  one  dram  of  mercurial 
ointment  is  given  at  a  time.  As  the  mercury  irritates 
the  skin,  it  should  not  be  rubbed  into  the  same  spot  on 
consecutive  days.  The  usual  sites  for  mercurial  inunction 
are  as  follows:  Right  axilla,  left  axilla,  space  in  front  of 
the  right  elbow,  space  in  front  of  left  elbow,  inner  surface 
of  the  right  thigh,  inner  surface  of  left  thigh.  In  carrying 
out  the  treatment  these  spaces  are  used  in  rotation  on 
successive  days;  a  day  is  then  allowed  to  elapse,  and  the 
cycle  begun  again  in  the  same  order.  In  rubbing,  the 
bare  hand  should  not  be  used,  or  the  operator  may  absorb 
the  drug.  A  smooth  glass  stopper  from  a  wide-mouthed 
bottle  makes  a  convenient  rubber.  Mercurial  inunction  is 
usually  given  in  connection  with  a  course  of  sweat-baths. 
It  should  be  given  after  the  bath  when  the  pores  are  open. 

Fumigation  is  more  rarely  used.  The  patient  is  ar- 
ranged as  for  a  vapor-bath  (see  Baths) ;  over  the  lamp, 
instead  of  the  kettle  of  water,  is  placed  a  metal  plate  con- 
taining the  drug  to  be  vaporized.  Mercury  is  the  principal 
drug  administered  in  this  manner,  but,  generally  speaking, 
inunction  is  preferred. 


CHAPTER  X 
POISONS  AND  THEIR  ANTIDOTES 

A  POISON  is  described  as  a  substance  "  which,  if  taken 
into  the  system,  produces  disease  or  death."  The  large 
majority  of  medicines,  if  taken  in  excessive  doses,  act  as 
poisons.  It  seems,  therefore,  essential  that  nurses  should, 
in  administering  medicines,  be  familiar  with  the  symptoms 
that  denote  overdosage. 

Symptoms  of  poisoning  may  arise  from  the  actual 
accumulation  of  an  excessive  quantity  of  a  drug  in  the 
system,  especially  in  patients  suffering  from  dropsy  (see 
p.  712)  or  from  the  drug  having  been  pushed  until  what 
is  known  as  the  "  physiologic  limit,"  or  the  limit  of  the 
normal  toleration  of  the  drug,  is  reached. 

On  the  first  appearance  of  any  such  symptom  the  drug 
is  withheld;  frequently  no  other  treatment  is  necessary, 
but  in  some  conditions,  such  as  digitalis  poisoning,  the 
physical  symptoms  are  severe  and  require  careful  treat- 
ment. 

Differing  from  the  above  are  the  cases  in  which  the 
poisoning  is  caused  by  an  overdose  of  a  powerful  drug, 
cither  through  carelessness  or  from  suicidal  intent.  The 
condition  is  one  of  acute  poisoning,  and  calls  for  prompt 
treatment. 

In  the  treatment  of  poisoning  three  steps  are  to  be 
observed:  (1)  Get  rid  of  the  poison.  (2)  Administer 
the  antidote.  (3)  Treat  the  physical  symptoms. 

If  the  poison  has  been  taken  by  mouth,  the  first  step  is 
to  empty  the  stomach,  either  by  lavage  or  by  the  admin- 
istration of  an  emetic,  following  which  the  antidote  is 
given. 

A  chemical  antidote  is  a  substance,  frequently  a  drug,  that 
acts  directly  on  the  poison  in  the  stomach  and  renders  it 

•24  369 


370  POISONS   AND   THEIR   ANTIDOTES 

inert.  It  has  no  effect  on  any  part  of  the  poison  already 
absorbed  into  the  system. 

A  physiologic  antidote  is  a  drug  or  substance  that  coun- 
teracts the  effects  of  the  poison  on  the  general  system. 

For  example,  in  poisoning  by  opium,  either  permangan- 
ate of  potash  or  tannic  acid  is  given  as  the  chemical  anti- 
dote. It  converts  the  opium  actually  in  the,  stomach  into 
an  inert  and  harmless  mass.  Atropin  in  its  physical  effects 
is  the  direct  antagonist  to  opium.  Opium  depresses  the 
respiratory  centers:  atropin  is  a  powerful  respiratory 
stimulant;  opium  increases  perspiration  by  checking  other 
secretions:  atropin  checks  perspiration  and  stimulates  the 
secretion  of  urine;  the  effect  of  opium  on  the  nervous 
system  is  shown  in  pinpoint  pupils:  of  atropin,  in  widely 
dilated  pupils.  In  cases  of  poisoning  by  opium,  atropin, 
therefore,  is  given  as  the  physiologic  antidote.. 

A  physiologic  antidote  must  always  be  administered 
with  caution,  or  one  poison  may  be  substituted  for  an- 
other. 

Lavage  may  be  given  with  plain  warm  water,  but  more 
commonly  the  chemical  antidote  is  used  as  a  lavage,  about 
half  a  pint  being  left  in  the  stomach  after  any  repetition 
of  the  process.  In  some  cases  it  is  necessary  to  repeat 
the  lavage  at  intervals  of  twenty  to  thirty  minutes. 
Once  the  chemical  antidote  is  considered  to  have  produced 
its  effect,  the  stomach  is  usually  washed  out  with  plain 
warm  water.  The  reason  for  this  is  that  the  inert  mass 
formed  by  the  poison,  combined  with  the  antidote,  may, 
by  the  action  of  the  digestive  secretion,  become  dissolved, 
and  the  poison  once  more  be  set  free. 

Emetics. — Warm  soapy  water,  salt  and  warm  water 
(2  drams  to  1  pint),  or  mustard  and  warm  water 
(2  drams  to  1  pint)  are  domestic  emetics  commonly  ob- 
tainable. One  or  two  glassfuls  are  usually  effectual.  If 
mustard  is  used,  it  should  be  followed  by  plain  water,  to 
prevent  irritation  to  the  lining  of  the  stomach.  Other 
safe  emetics,  generally  at  hand  in  hospital  work,  are  as 
follows : 

Sulphate  of  zinc,  15  grains  in  a  tumbler  of  warm  water, 
repeated,  if  necessary,  in  fifteen  minutes. 


EMETICS  371 

Carbonate  of  ammonia,  30  grains  in  a  tumbler  of  warm 
water  or  milk,  repeated,  if  necessary,  in  fifteen  minutes. 

Ipecacuanha  wine,  4  drams  to  1  ounce,  every  quarter 
of  an  hour  until  the  result  is  obtained. 

Apomorphin  is  a  powerful  emetic,  used  when  prompt 
emesis  is  necessary  or  where  the  patient  is  unable  to  swal- 
low. It  is  given  as  a  hypodermic  injection,  in  doses  of  -^ 
grain.  It  is  usually  effective  in  about  five  minutes.  If 
no  result  is  shown  in  ten  minutes,  the  dose  is  repeated — 
generally  the  second  dose  is  effectual. 

Where  the  nature  of  the  poison  is  known,  the  treatment 
of  the  condition  is  simple.  In  many  cases  the  patient  is 
not  seen  until  unconscious,  and  no  history  is  obtainable. 
The  objective  symptoms  are  then  of  the  first  importance 
in  determining  the  diagnosis.  The  following  points 
should  be  npted :  The  physical  condition,  whether  stimu- 
lated or  depressed;  the  presence  of  pain,  vomiting,  and 
the  appearance  and  smell  of  the  vomitus;  nervous  symp- 
toms, such  as  sleep,  unconsciousness,  delirium,  or  convul- 
sions; the  smell  of  the  breath;  contraction  or  dilatation  of 
the  pupils;  marks  of  burns  about  the  lips  and  mouth. 

In  carrying  out  the  treatment  care  must  be  taken  never 
to  exhaust  the  patient.  In  cases  where  collapse  has  al- 
ready occurred,  or  where  the  poison  used  has  a  depressing 
action  on  the  heart  (aconite,  digitalis,  etc.),  lavage  is 
used  in  preference  to  emetics,  and  the  patient  should 
be  kept  strictly  lying  down  during  the  process,  with  the 
head  low. 

It  must  be  borne  in  mind  that  most  poisons  are  elimin- 
ated by  the  intestines  and  the  kidneys,  and  both  should 
be  kept  active.  If  urine  is  suppressed,  the  catheter  should 
be  passed,  as  there  is  some  possibility  of  the  poison  ex- 
creted by  the  kidney  being  reabsorbed  from  the  bladder. 

In  all  cases  of  poisoning  it  should  be  a  rule  that  all  the 
urine  passed  should  be  saved  for  examination  and  carefully 
measured.  The  vomitus  also  should  be  kept,  as  an  aid  to 
diagnosis. 

Poisons  may  be  considered  in  three  groups: 

Corrosive. — Those  that  corrode  or  destroy  the  tissues 
with  which  they  come  in  contact. 


372  POISONS   AND   THEIR   ANTIDOTES 

Irritants, — Those  that  irritate  the  tissues.  Taken  in 
large  quantities  or  in  concentrated  form,  the  irritants  will 
act  as  corrosives  on  the  tissues. 

Functional  Poisons. — Those  that  act  on  one  or  other 
of  the  organs,  interfering  with  their  function,  and  causing 
direct  and  indirect  physiologic  symptoms. 

CORROSIVE  POISONS 

The  common  corrosive  poisons  are  the  acids — acetic, 
carbolic,  citric,  hydrochloric  (muriatic),  hydrocyanic 
(prussic),  nitric,  oxalic,  sulphuric  (vitriol),  tartaric — and 
the  alkalis — ammonia,  lime,  caustic  potash,  carbonate  of 
soda  (washing-soda),  and  nitrate  of  potash  (saltpeter). 

Many  of  the  above  are  given  in  small,  highly  diluted 
doses,  as  medicines,  chiefly  tonic  in  their  action. 

Symptoms. — The  general  symptoms  of  poisoning  by 
corrosives  are:  Corrosion  of  the  mucous  membrane 
lining  the  mouth,  esophagus,  and  stomach,  evinced  by 
whitening  and  burns  about  the  lips  and  mouth,  the  injury 
frequently  being  so  severe  as  completely  to  destroy  the 
membranes;  acute  pain  in  mouth  and  abdomen;  vomiting, 
usually  of  mucus  and  blood,  and  acid  or  alkaline  in  reac- 
tion, according  to  the  nature  of  the  poison;  bloody  stools; 
frequently  bloody  frothing  at  the  mouth;  giddiness;  rapid 
collapse;  coma,  or  sudden  failure  from  paralysis  of  the 
heart.  Convulsions  may  occur.  Perforation  of  the 
stomach  or  intestines  is  not  uncommon. 

Poisoning  by  corrosives  is  the  most  fatal  form  of  poison- 
ing. In  severe  cases  (nitric  acid,  sulphuric  acid,  or  strong 
alkalis)  death  occurs  rapidly  from  shock  and  the  local 
effect  of  the  corrosive.  Partial  recovery  may  take  place, 
and  the  patient  die  eventually  either  from  the  local  or 
physiologic  effects  of  the  poison.  If  recovery  takes  place, 
scarring  of  the  tissues  is  a  common  cause  of  stricture  of 
the  esophagus.  Death  may  also  result  from  starvation 
caused  by  injury  to  so  large  a  surface  of  the  alimentary 
canal. 

A  routine  treatment  is  common  to  all  forms  of  corrosive 
poisoning. 


CORROSIVE   POISONS  373 

Emetics  are  rarely  used,  the  violent  muscular  con- 
traction caused  by  emesis  tending  to  injure  the  tissues 
further. 

Lavage  is  given  promptly,  where  possible  (i.  e.,  unless 
the  local  injury  is  too  severe),  and  should  contain  the  anti- 
dote. 

The  natural  antidote  to  an  acid  is  an  alkali.  In  poison- 
ing by  the  acids  the  alkalis — lime,  chalk,  magnesia  (sul- 
phate), or  soda  (sulphate) — are  given  as  a  lavage  or  as 
drinks  stirred  up  in  milk.  Warm  soapy  water  is  a  con- 
venient alkaline  lavage. 

The  natural  antidote  to  an  alkali  is  an  acid.  Vinegar 
and  water  is  used  as  a  lavage,  and  the  dilute  acids,  vinegar, 
or  lemon-juice  in  water,  are  given  by  mouth. 

The  antidote  is  followed  by  oil  (exception,  carbolic-acid 
poisoning),  milk,  the  white  of  eggs,  and  bland  drinks,  such 
as  flaxseed  tea  or  barley-water. 

External  heat  is  applied,  and  stimulants  given  by  hypo- 
dermic. Morphin  is  usually  necessary  to  allay  the  pain. 

Convalescence  is  slow.  The  diet  should  consist  of 
milk,  egg-albumen,  and  bland  drinks.  The  kidneys  are 
usually  in  an  irritated  condition,  and  the  urine  should 
be  measured  and  examined.  Strychnin  and  other  cardiac 
stimulants  are  given  by  hypodermic. 

Certain  special  points  should  be  carefully  remembered. 

In  poisoning  by  carbolic  acid,  the  antidote,  alcohol,  is 
given  freely  as  a  lavage  and  by  mouth. 

Neither  oils  nor  glycerin  can  be  given,  as  they  dissolve 
the  acid  and  promote  its  absorption. 

In  poisoning  by  oxalic  acid  (usually  taken  by  mistake 
for  Epsom  salts)  either  lime  or  chalk  of  the  alkalis  should 
be  used,  the  union  of  some  of  the  others  forming  poisonous 
compounds. 

Of  the  acids,  sulphuric  add  and  nitric  acid  have  the  most 
violent  corrosive  action  on  the  tissues,  in  concentrated 
form  completely  destroying  the  membranes.  The  symp- 
toms are  violent,  the  collapse  profound  and  rapid.  Per- 
foration frequently  results.  The  vomitus  is  stained  char- 
acteristically tarry  from  sulphuric  acid,  and  yellow  from 
nitric  acid. 


374 


POISONS   AND   THEIR   ANTIDOTES 


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IRRITANT   POISONS  375 

In  poisoning  by  hydrocyanic  acid  death  usually  occurs 
too  rapidly  for  treatment.  Collapse  is  sudden.  There 
may  be  convulsive  movements  of  the  toes  and  fingers,, 
or  complete  muscular  relaxation.  The  eyes  are  usually 
prominent  and  the  pupils  dilated.  If  there  is  time,  the 
treatment  consists  in  artificial  respiration,  cold  and  hot 
water  dashed  alternately  on  the  spine  and  in  the  face, 
external  heat,  and  stimulants  by  hypodermic. 

IRRITANT  POISONS 

The  larger  proportion  of  the  irritant  poisons  are  the 
metals,  such  as  alum,  antimony,  arsenic,  copper,  lead, 
mercury,  silver  nitrate,  and  zinc.  Other  irritants  are 
iodin,  cantharides,  phosphorus,  and  turpentine.  The 
fumes  of  certain  gases  are  also  considered  as  irritant 
poisons. 

A  certain  similarity  may  be  noticed  in  the  physical  symp- 
toms following  poisoning  by  the  metals  and  other  irritants. 

The  physiologic  dose  is  characterized  by  digestive  dis- 
turbance, diarrhea  with  cramping  pains,  salivation,  fre- 
quently coryza,  and,  in  the  case  of  the  metals,  by  a  metallic 
taste  in  the  mouth. 

Poisonous  doses  cause  acute  burning  pain  at  the  epi- 
gastrium, colic,  vomiting,  and  purging,  with  watery  stools. 
The  vomitus  and  the  stools  may  contain  blood.  Prostra- 
tion is  marked,  and  severe  cases  frequently  end  in  fatal 
collapse.  Nervous  symptoms  are  common,  such  as 
muscular  cramps,  especially  in  the  legs,  convulsions,  or 
some  form  of  paralysis.  The  kidneys  are  irritated,  the 
urine  scanty,  albuminous,  or  bloody,  and  frequently 
suppressed. 

The  chronic  form  of  poisoning  is  associated  with  anemia, 
emaciation,  muscular  weakness,  local  paralysis,  and  di- 
gestive disturbances. 

Acute  Poisoning. — In  the  treatment  of  acute  poison- 
ing the  stomach  is  emptied  either  by  emetics  or  by  lavage. 
The  chemical  antidote  is  usually  some  soluble  sulphate  or 
egg-albumen.  It  should  be  administered  promptly,  and 
usually  in  repeated  doses.  For  the  reasons  already  stated, 


376  POISONS   AND   THEIR   ANTIDOTES 

a  lavage  of  plain  water  should  follow  the  administration 
of  the  chemical  antidote  once  the  effect  of  the  antidote 
is  established. 

The  further  treatment  common  to  all  cases  of  acute 
poisoning  by  the  irritants  consists  in  hot  applications  to 
the  abdomen,  stimulants  administered  by  hypodermic 
injection,  and  external  heat.  The  recumbent  position  is 
enforced,  and,  where  the  heart  is  much  depressed,  as  shown 
by  a  small,  feeble,  irregular  pulse,  the  bottom  of  the  bed 
should  be  elevated  and  the  head  kept  low.  Opium  is 
frequently  necessary  to  relieve  the  acute  pain,  and  is 
ordered  in  extreme  cases;  it  is,  however,  avoided,  if  pos- 
sible, on  account  of  its  constipating  properties,  wrhich 
hinders  the  prompt  elimination  of  the  poison.  Opium  is 
not,  as  a  rule,  given  where  the  poison  causes  marked  symp- 
toms of  congestion  of  the  kidneys.  Castor  oil  is  commonly 
given  to  hasten  the  elimination  of  the  poison.  Egg- 
albumen,  milk,  and  bland  drinks  are  given,  as  in  the  treat- 
ment of  corrosive  poisoning.  Oil  may  also  be  given  for 
its  soothing  effect  on  the  tissues,  except  in  poisoning  from 
cantharides  or  phosphorus.  As  with  carbolic  acid,  oil 
dissolves  these  substances  and  makes  them  more  readily 
absorbable. 

As  many  of  the  irritant  poisons  are  in  common  use  as 
medicines,  nurses  should  be  familiar  with  the  symptoms  of 
intoleration,  as  well  as  with  the  symptoms  and  treatment 
of  poisonous  doses.  For  convenience,  the  two  are  de- 
scribed together. 

Convalescence  from  the  acute  poisoning  is  always 
very  slow,  and  death  may  occur  after  the  lapse  of  several 
days. 

Prolonged  rest  in  bed  cardiac  stimulants,  and  soft  diet 
until  the  tissues  are  quite  healed,  are  the  common  lines  of 
treatment.  If  the  kidneys  are  affected,  no  nitrogenous 
foods  are  given  until  the  urine  is  normal.  In  these  cases 
the  urine  must  be  measured  and  examined  daily. 

Sequelae,  such  as  nephritis,  local  paralysis,  pronounced 
anemia,  and  other  physical  manifestations,  such  as  jaun- 
dice (in  phosphorus-poisoning),  may  follow  poisoning  by 
one  or  other  of  the  irritant  poisons. 


IRRITANT   POISONS 


377 


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THE    FUNCTIONAL   POISONS  381 

The  chronic  forms  of  poisoning  (arsenic,  lead,  cop- 
per, etc.)  are  treated  by  withdrawal  of  the  cause,  good 
hygiene,  rest,  and  nourishing  diet.  Local  paralysis  is 
treated  with  massage,  and,  usually,  the  alkaline  tonics 
are  prescribed. 

THE  FUNCTIONAL  POISONS 

The  large  majority  of  the  functional  poisons  belong  to  the 
vegetable  kingdom.  All  of  them  are  in  constant  use  as 
medicines;  the  early  recognition  of  the  full  physiologic 
effect  of  each  drug  is  of  importance. 

The  treatment  of  the  toxic  condition  must,  obviously, 
be  governed  by  the  effect  produced  by  the  drug. 

Lavage  or  emetics  are  employed  to  empty  the  stomach. 
In  a  number  of  cases,  especially  in  poisoning  by  the  vege- 
table alkaloids,  tannic  acid  is  the  chemical  antidote  (10 
grains  to  1  pint).  It  is  given  as  a  lavage,  repeated  from 
time  to  time,  some  of  the  solution  being  left  in  the  stomach 
after  each  lavage,  and  a  final  lavage  of  plain  water;  or  it 
may  be  given  by  mouth  in  repeated  doses,  a  glassful  at 
a  time  every  ten  minutes,  followed  finally  by  lavage  of 
plain  water.  Tannic  acid  may  also  be  given  in  the  form 
of  very  strong  tea. 

Permanganate  of  potash  is  also  a  common  antidote, 
especially  for  the  vegetable  alkaloids,  and  is  used  in  the 
same  manner  as  tannic  acid.  Sufficient  of  the  crystals  to 
color  the  water  dark  pink  is  the  usual  strength. 

The  alkaloids  of  many  of  these  drugs  are  commonly 
given  by  hypodermic,  and  it  is  obviously  futile  to  empty 
the  stomach.  Reliance  must  then  be  placed  on  counter- 
acting the  physical  symptoms.  An  exception  is  met  with 
in  some  drugs  which  are  actually  excreted  in  the  stomach, 
of  which  opium  is  an  important  example.  The  same  is 
true  in  cases  where  the  toxic  condition  is  due  to  an  accumu- 
lation of  the  drug  in  the  system,  as  already  explained, 
the  individual  dose  being  harmless.  In  many  cases  also 
by  the  time  the  effects  of  poisoning  are  manifested  little 
of  the  poison  remains  in  the  stomach,  and  to  administer 
emetics  or  lavage  is  merely  unnecessarily  exhausting. 

These  drugs  are  excreted  in  the  urine  and  by  the  bowels. 


382  POISONS   AND  THEIR   ANTIDOTES 

Elimination  is  hastened,  therefore,  by  keeping  the  kidneys 
and  the  bowels  active.  Urine  should  not  be  allowed  to 
accumulate  in  the  bladder  or  the  drug  may  be  reabsorbed 
from  the  urine.  If  the  urine  is  not  passed  voluntarily, 
the  catheter  should  be  used.  The  urine  should  in  all 
cases  be  saved  for  examination. 

Many  of  the  functional  poisons  have  an  intensely 
depressing  effect  on  the  heart;  for  example,  aconite, 
digitalis.  In  the  treatment  of  these  cases  a  small  exer- 
tion on  the  part  of  the  patient  may  cause  a  fatal  syncope. 
Where  possible  (i.  e.,  unless  there  is  the  condition  of  orthop- 
nea),  the  recumbent  position  must  be  enforced  and  the 
head  kept  low.  Emetics  must  be  avoided,  and  lavage  given 
with  caution.  If  emesis  occurs,  the  vomitus  should  be 
received  on  a  towel  without  the  head  being  raised.  In 
the  treatment  of  all  poisons,  and  especially  of  poisons 
belonging  to  this  class,  the  strength  of  the  patient  must  be 
carefully  husbanded.  Besides  the  recumbent  position 
and  external  warmth,  the  treatment  commonly  comprises 
the  cardiac  stimulants  by  hypodermic  or  rectum,  and 
infusion  of  normal  salt  solution. 

On  account  of  the  importance  of  these  drugs  as  medicines 
and  their  very  varied  effects,  the  symptoms  and  treatment 
of  overdose  and  poisoning  is  given  at  greater  length. 

Aconite. — Action. — Depressant,  lowering  the  rate  and  volume  of 
the  pulse;  sedative,  diuretic,  diaphoretic,  antipyretic. 

Preparations. — Tincture  of  aconite  (1  to  4  minims);  aconitum 
(vfa  to  TV  grain). 

Physiologic  Dose. — Pulse  small,  soft,  slow;  respiration  slow,  deep; 
vertigo,  weakness;  sensation  of  tingling  on  the  tongue. 

Treatment. — Withdrawal  of  drug;  the  recumbent  position; 
no  sudden  movements;  cardiac  stimulants. 

Poisonous  Dose. — Tingling  sensation;  pulse  very  slow  and  irreg- 
ular (30  to  40);  respiration  slow  and  irregular;  temperature  sub- 
normal; muscular  weakness,  profound  depression,  sweating;  fre- 
quently vomiting;  dilated  pupils;  finally,  collapse. 

Treatment. — Lavage  with  tannic  acid;  external  heat;  the  recum- 
bent position  with  the  head  low;  stimulants,  especially  atropin,  on 
account  of  its  prompt  action;  infusion  of  normal  salt  solution. 
Artificial  respiration  may  be  necessary.  The  greatest  care  must  be 
taken  not  to  exhaust  the  patient  or  in  any  way  tax  the  depressed  heart . 

After-treatment. — Rest  in  bed  until  the  pulse  is  normal.  Digitalis 
and  alcoholic  stimulants  are  usually  ordered. 

Alcohol. — Intoxication  by  alcohol  in  any  form  produces  exal- 


THE   FUNCTIONAL   POISONS  383 

tation,  staggering  gait,  deep  sleep  with  stertorous  breathing,  acute 
gastritis,  and,  finally,  profound  depression. 

Treatment. — Emetics  or  lavage.  Gastric  symptoms  treated  by 
diet  and  purgatives.  Death  may  occur  from  paralysis  of  the  heart, 
and  has  been  known  to  take  place  several  days  after  recovery  has 
apparently  been  assured. 

Antipyrin. — Action. — Reduces  temperature,  relieves  mild  nervous 
conditions,  such  as  migraine,  sleeplessness,  etc. 

Preparation. — Powder  (5  to  15  grains). 

Physiologic  Dose. — In  full  or  too  frequent  doses  produces  marked 
depression,  with  syncope,  cyanosis,  feeble,  irregular  pulse,  rapid 
respiration,  and  collapse.  A  skin  eruption  often  resembling  the 
rash  of  measles  is  common. 

Acetanilid  (antifebrin)  and  preparations  containing  acetanilid — 
antikamnia,  antinervine,  etc. — and  phenacetin  produce  effects  similar 
to  antipyrin. 

Treatment. — Recumbent  position,  external  heat,  stimulants, 
hot  coffee,  rest  in  bed  until  the  pulse  is  normal. 

In  large  amounts  taken  accidentally  antipyrin  and  its  derivatives 
are  corrosive  poisons. 

Belladonna. — Action. — Deliriant,  respiratory  and  cardiac  stimu- 
lant; antispasmodic;  anodyne;  checks  all  secretion  except  urine; 
dilates  the  pupils. 

Preparations. — Tincture  of  belladonna  (10  to  30  minims) ;  atropin 
sulphate  (^G  to  7V  grain).  Atropin  and  its  derivative,  homatropin, 
are  used  as  mydriatics. 

Physiologic  Dose. — -Dryness  of  the  nose  and  throat,  pulse  rapid 
and  full,  excitement,  dilated  pupils,  rise  of  temperature,  saliva  and 
sweat  checked,  thirst,  skin  rash  suggesting  scarlatina. 

Treatment. — Withdrawal  of  the  drug;  water  freely;  cold  sponging 
or  packs;  sedatives,  such  as  the  bromids,  may  be  necessary. 

Poisonous  Dose. — All  the  above  symptoms  intensified.  Wild  and 
noisy  delirium.  In  fatal  cases  convulsions,  paralysis,  and  coma. 

Treatment. — Lavage  with  the  chemical  antidote,  tannic  acid.  Cold 
sponging  or  packs,  ice-bag  to  head.  In  collapse,  coffee  and  brandy- 
en  ema,  external  heat,  normal  salt  infusion.  Morphin,  the  physiologic 
antidote,  may  be  given  by  hypodermic.  Pilocarpin  may  be  ordered  (o 
induce  sweating,  and,  more  rarely,  physostigma,  or  its  alkaloid,  eserin, 
is  given.  If  morphin  is  not  used,  the  bromids  are  generally  given. 

Chloral. — Action. — Narcotic;  antispasmodic;  depressant. 

Preparations. — Chloral  hydrate  (10  to  20  grains);  chloralamid 
(15  to  30  grains). 

Physiologic  Dose. — Sleep,  syncope,  cyanosis,  irregular  pulse. 
Chloral  should  always  be  given  with  caution.  An  ordinary  dose 
has  been  known  to  cause  death  from  paralysis  of  the  heart. 

Treatment. — Fresh  air,  rousing,  stimulants,  friction  of  extremities, 
external  heat. 

Poisonous  Dose. — Profound  sleep,  passing  into  coma;  pulse  at 
first  slow,  feeble,  and  irregular,  later  rapid  and  thready;  respiration 
slow  and  shallow;  subnormal  temperature;  syncope;  cyanosis; 
clammy  skin;  pupils  first  contracted,  then  widely  dilated.  Death 
occurs  from  paralysis  of  the  heart. 

Treatment. — Lavage  with  strong  coffee  or  tea;  fresh  air;  rousing; 
recumbent  position,  with  the  head  low;  external  heat;  stimulants, 
especially  atropin  or  strychnin,  by  hypodermic;  hot  coffee  and 


384  POISONS   AND  THEIR  ANTIDOTES 

alcoholic  stimulants  by  mouth  or  enema;  amyl  nitrite  by  inhalation; 
oxygen;  the  electric  battery;  artificial  respiration.  The  patient  must 
be  spared  all  exertion. 

Cocain  Hydrochloric!  (Alkaloid  of  Coca). — Action. — Stimulant, 
deliriant.  Chiefly  used  as  a  local  anesthetic  by  hypodermic  injec- 
tion. Acts  also  as  a  mydriatic. 

Preparation. — In  solution,  2,  4,  etc.,  per  cent.  As  a  stimulant, 
i  to  i  grain. 

Poisonous  Dose. — Excitement,  incoherence,  nausea,  vomiting; 
later,  marked  depression,  with  small,  rapid  pulse,  slow  respiration, 
cyanosis,  dilated  pupils,  and  syncope  or  collapse. 

Treatment. — Lavage  of  plain  water  (if  taken  by  mouth).  In 
collapse,  recumbent  position,  external  heat,  alcoholic  stimulants, 
coffee  enema,  amyl  nitrite  inhalations,  artificial  respiration,  saline 
infusion.  The  physiologic  antidote  is  opium,  given  as  morphin 
sulphate  by  hypodermic  injection.  Cocain  is  also  a  drug  which 
induces  a  habit. 

Digitalis. — Action. — Cardiac  stimulant  and  tonic;  diuretic. 

Preparations. — Tincture  of  digitalis  (5  to  20  minims);  infusion, 
(1  to  4  drams);  digitalin  (5^  grain). 

Physiologic  Dose. — Headache,  nausea,  vomiting,  diarrhea,  dis- 
turbances of  vision,  slow,  full  pulse,  becoming  rapid  on  slight  ex- 
ertion. 

Treatment. — Withdrawal  of  drug,  recumbent  position,  alcoholic 
stimulants,  or  strychnin. 

Poisonous  Dose. — The  above  symptoms  intensified.  Small,  ir- 
regular pulse,  with  "  wild  "  heart,  protruding  eyes,  with  blue  tinge 
to  the  whites,  marked  prostration,  and  collapse. 

Treatment. — If  a  poisonous  dose  has  been  taken  (rare),  prompt 
lavage  with  tannic  acid.  The  recumbent  position  absolutely 
(except  in  orthopnea),  external  heat,  stimulants,  especially  alcohol 
and  strychnin.  All  exertion  must  be  avoided  until  the  pulse  is 
restored. 

Hyoscyamus  resembles  belladonna  in  its  action  and  toxic  effects. 
The  treatment  of  poisoning  by  hyoscyamus  or  its  preparations  is  the 
same  as  in  belladonna-poisoning  (see  Belladonna). 

Mushroom-poisoning  has  marked  depressing  action  on  the  sys- 
tem, causing  collapse,  cyanosis,  and  syncope,  with  small,  feeble  pulse 
and  shallow  respiration;  vomiting  and  purging  may  be  present. 

Treatment. — Lavage  with  tannic  acid;  hot  strong  tea;  external 
heat.  Alcoholic  stimulants,  coffee  and  brandy  enema,  saline  infusions. 
Physiologic  antidote  is  atropin,  T$T  to  •£$  grain. 

Opium. — Many  alkaloids,  of  which  the  principal  are  morphin, 
codein,  and  heroin.  Morphin  only  has  narcotic  action. 

Principal  Preparations. — Tincture  of  opium,  20  to  30  minims; 
camphorated  tincture  of  opium  or  paregoric,  1  to  4  drams  (contains 
opium,  2  grains  in  each  ounce);  morphin  sulphate,  T:j  to  i  grain; 
Dover's  powder  (contains  opium,  1  grain  in  every  10  grains),  5  to 
10  grains. 

In  acute  opium-poisoning  there  are  three  stages,  with  character- 
istic symptoms. 

First  stage:   happy,  sleepy,  painless  state,  passing  into  sleep. 

Second  stage:  sleep  from  which  the  victim  can  be  roused.  Slow 
respirations;  pulse  slow  and  full;  skin  flushed  and  dry;  contracted 
pupils;  retention  of  urine. 


THE   FUNCTIONAL   POISONS  385 

Third  stage:  profound  sleep,  passing  into  coma;  respiration  very 
slow  and  shallow,  toward  the  end,  two  to  four  a  minute;  rapid  pulse, 
generally  thready,  cyanosis;  clammy  sweat;  pin-point  pupils;  just 
before  death  the  pupils  dilate  widely. 

The  most  important  symptom  to  watch  in  opium-poisoning 
(and  all  narcotic  poisoning)  is  the  rate  of  the  respiration.  Where 
the  rate  does  not  sink  below  10  to  12,  the  chances  of  recovery  are 
good,  and  any  improvement  in  the  rate  of  respiration  is  always 
a  favorable  symptom.  In  administering  opium  in  any  form  nurses 
should  be  taught  to  report  at  once  any  drop  in  the  rate  of  respiration. 

Treatment. — Chemical  antidotes,  permanganate  of  potash  or 
tannic  acid,  given  as  lavage  or  in  a  weak  solution  by  mouth. 

The  treatment  aims  at  stimulating  the  respiratory  and  cardiac 
centers,  and  the  urgency  of  the  treatment  is  guided  by  the  condition 
of  the  respiration  and  pulse.  If  both  are  good,  the  patient  is  allowed 
to  sleep  off  the  effects  of  the  poison.  Commonly,  drastic  treatment 
is  necessary.  The  patient  is  kept  awake  by  constant  movement, 
cold  water  dashed  in  the  face  and  over  the  spine,  black  coffee  by 
enema  and  mouth;  fresh  air  is  supplied  freely;  artificial  respiration 
and  electricity  may  be  necessary.  Atropin  is  the  physiologic  anti- 
dote, and  is  given  by  hypodermic  in  doses  larger  than  the  average; 
alcoholic  stimulants  and  strychnin  may  also  be  used.  If  the  urine  is 
not  voided,  the  bladder  must  be  emptied  to  prevent  rcabsorption  of 
the  drug  from  the  bladder.  From  the  first  and  second  stages 
recovery  is  usual,  the  third  stage  once  reached  is  generally  fatal. 

Stramonium. — Alkaloid,  daturin.  In  its  action  and  toxic  effects 
resembles  belladonna.  The  treatment  of  the  poisoning  is  the  same  as 
in  belladonna  (see  Belladonna). 

Strychnin. — Alkaloid,  strychnin  sulphate. 

AcMon. — General  nerve  stimulant  and  tonic  acting  on  all  the  im- 
portant nerve-centers. 

Preparations. — Tincture nux vomica  (about  2  percent,  strychnin), 
5  to  20  minims;  strychnin  sulphate,  ^  to  &  grain. 

Physiologic  Dose.— Given  over  lengthened  periods  or  in  too  full 
or  too  frequent  doses,  strychnin  produces  excitement,  overstimula- 
lion  of  the  special  senses,  especially  hearing,  cardiac  disturbance, 
and  muscular  twitchings  beginning  at  the  fingers  and  toes. 

Treatment. — Withdrawal  of  the  drug,  rest  (in  bed  if  the  symptoms 
are  severe),  freedom  from  strain  and  excitement;  the  bromids  are 
given  and  pushed  until  the  full  effect  is  obtained. 

Poisonous  Dose. — In  poisonous  quantities,  usually  taken  with 
suicidal  intent,  strychnin  produces  typical  convulsions  resembling 
those  of  tetanus  or  lock-jaw,  with  certain  marked  differences.  (Sec 
p.  683.)  The  convulsion  begins  at  the  extremities  and  quickly  in- 
volves the  whole  frame;  the  jaws  arc  the  last  to  be  affected;  between 
the  convulsions  the  muscles  are  completely  relaxed;  the  eyes  remain 
open  and  staring;  the  mouth  has  a  horrible  grin;  consciousness  is 
maintained  to  the  end. 

Treatment. — Prompt  lavage  with  the  chemical  antidote,  tannic 
acid,  or  emetic  followed  by  tannic  acid  or  animal  charcoal;  inhalation 
of  chloroform  during  convulsions;  chloral  and  bromid  in  full  doses 
by  enema  or  stomach.  The  bladder  must  be  emptied — by  catheter, 
if  necessary.  Absolute  quiet  is  imperative,  a  slight  sound  causing  a 
fresh  convulsion;  in  collapse,  external  heat,  saline  infusion,  and  alco- 
holic stimulants  are  given. 


386  POISONS  AND  THEIR   ANTIDOTES 

Veratrum  Viride. — Action. — Cardiac  depressant,  reduces  pulse, 
both  in  strength  and  frequency. 

Preparations. — Tincture  of  veratrum  viride,  2  to  10  minims. 
Frequently  ordered  2  minims  every  hour  until  the  desired  effect 
is  produced. 

Poisonous  Dose. — Complete  prostration,  nausea,  and  violent 
vomiting.  The  pulse  is  first  abnormally  slow  and  soft,  later  small, 
rapid,  and  thready.  As  emesis  is  at  once  produced,  poisoning  by 
veratrum  is  rarely  fatal. 

Treatment.- — The  recumbent  position  absolutely,  with  the'  head 
low;  lavage  of  plain  water;  stimulants  by  hypodermic;  hot  coffee 
enema;  saline  infusion;  external  heat;  friction  to  the  extremities. 

Some  drugs  which  have  not  a  toxic  effect  produce  char- 
acteristic groups  of  symptoms  if  taken  for  lengthened 
periods  or  in  full  doses.  The  most  important  are  as 
follows: 

Bromids. — Action. — Sedative. 

Preparation. — In  combination  with  the  alkalis,  potassium, 
sodium,  etc.,  10  to  30  grains. 

A  group  of  symptoms  known  as  bromism.  Mental  and  physical 
inertia,  apafhy,  dulness,  fetor  of  breath,  gastric  disturbance,  and 
acne  rash. 

On  withdrawal  of  the  drug  the  symptoms  usually  disappear. 
Arsenic  is  sometimes  given  to  correct  the  skin  condition. 

Quinin. — Action. — Tonic,  antipyretic,  specific  in  malaria. 

Preparations. — Quinin  sulphate  (2  to  10  grams),  and  in  combina- 
tion with  other  drugs. 

Full  doses  of  quinin  cause  a  sensation  of  ringing  in  the  ears  and 
deafness;  skin  eruptions  frequently  follow,  either  resembling  urticaria 
or  the  rash  of  scarlet  fever.  The  condition  is  called  cinchonism. 

Usually  the  drug  is  withdrawn  and  no  further  treatment  is  neces- 
sary. An  idiosyncrasy  against  quinin  is  not  uncommon.  In 
persons  with  this  characteristic  or  after  an  abnormally  large  dose, 
quinin  may  cause  syncope  and  prostration. 

Treatment. — The  recumbent  position;  fresh  air;  alcoholic  stimu- 
lants; strong  coffee;  external  heat. 

Salicylic  Acid. — Action. — Antipyretic,  specific  in  rheumatism. 

Preparations. — Salicylic  acid  (5  to  20  grains);  sodium  salicylate 
(5  to  20  grains).  Full  doses  produce  a  group  of  symptoms  known  as 
salicism,  characterized  by  buzzing  and  roaring  in  the  ears,  deafness, 
headache,  sense  of  great  depression,  and  physical  weakness.  Some 
albuminuria  is  usually  present.  A  rash,  usually  resembling  urticaria, 
is  not  uncommon. 

Treatment.— The  drug  is  withdrawn.  Rest  and  the  moderate  use 
of  alcoholic  stimulants  may  be  necessary. 

In  some  rare  instances  marked  dyspnea  and  delirium  follow 
overdosing  by  the  salicylates. 

Snake-bite. — The  poison  from  a  snake-bite  has  a  rapidly  depress- 
ing action  on  the  vital  centers.  Free  stimulation  with  alcohol  or 
strychnin  should  be  given  promptly,  external  heat  should  be  applied, 
and  the  recumbent  position  inforced.  Cupping  over  the  wound  is 
sometimes  recommended,  or  means  to  encourage  bleeding.  Recov- 
ery from  snake-bite  is  not  uncommon. 


CHAPTER  XI 

ELEMENTARY  BACTERIOLOGY  AND  THEORIES 
OF  IMMUNITY 

Classification  of  Bacteria,  Morphology,  Parasites — Examination 
of  Bacteria — Microscope,  Smear,  Staining,  to  Stain  Tubercle  Bacil- 
lus, the  Hanging  Drop,  Widal  Reaction — Cultivation  of  Bacteria, 
Plating,  Culture-media,  to  Take  a  Culture — Invasion  of  the  System 
by  Bacteria — Varieties  of  Toxins — Koch's  Postulates — Pathogenic 
Organisms  Already  Discovered — Air-borne  Infections,  Droplet 
Infection,  Water-borne  Infection,  Infection  through  the  Broken 
Surface,  by  Inoculation,  Transmitted  by  Insects — Prophylaxis  of 
Infectious  Diseases — Immunity — Natural,  Acquired,  Active,  Pas- 
sive— Vaccination,  Inoculation,  Antitoxins — Theories  of  Immunity — 
The  Feeding  Cell,  Side-chain  Theory,  Opsonic  Theory — Incubation 
— Protection  Against  Contagion  in  Special  Infections. 

CLASSIFICATION 

So  large  a  portion  of  our  work  is  the  practical  outcome 
of  modern  research  in  bacteriologic  laboratories,  so 
greatly  is  it  influenced  by  the  theories  and  deductions  of 
modern  scientists,  that  some  accurate,  if  elementary, 
knowledge  of  the  more  prominent  facts  of  bacteriology 
should  be  available  to  the  pupil  nurse  from  the  earliest 
days  of  her  training. 

Bacteriology,  or  the  study  of  micro-organisms,  belongs 
to  modern  times,  and  especially  to  later  years,  where  three 
important  factors  have  made  possible  an  accurate  study 
of  the  life-history  of  these  minute  bodies  not  possible  be- 
fore. These  three  factors  are:  first,  the  perfection  of  the 
microscope;  second,  the  discovery  of  a  method  of  isolating 
the  individual  organism  in  "pure  culture  ";  and,  third,  the 
discovery  of  a  means  of  differentiating  micro-organisms 
by  staining  them  with  anilin  dyes. 

Bacteria  are  unicellular  micro-organisms  of  vegetable 
origin.  Their  structure  is  of  the  simplest,  consisting  of 
protoplasm  surrounded  by  a  cell-wall  and  devoid  of 
nucleus.  In  common  with  other  similar  micro-organisms, 

387 


388      ELEMENTARY   BACTERIOLOGY   AND    IMMUNITY 

they  are  also  known  as  germs  or  microbes.  They  resemble 
the  lowest  form  of  vegetable  life — the  fungi. 

Fungi  differ  from  ordinary  plant  life  in  their  method  of 
development,  in  the  food  which  they  require,  the  condi- 
tions in  which  they  nourish,  and  in  the  fact  that  they 
possess  no  chlorophyl.  Chlorophyl  is  the  green  coloring- 
matter  of  plants  which  is  essential  to  their  growth.  It 
makes  possible  in  the  plants  the  process  of  chemical  change 
(accomplished  in  our  bodies  by  the  processes  of  digestion 
and  assimilation),  by  which  the  plant,  under  suitable  con- 
ditions of  sunshine  and  moisture,  can  take  up  carbon 
dioxid  from  the  atmosphere,  and  convert  it  into  the  essen- 
tial elements  of  plant  structure.  Fungi,  which  have  no 
chlorophyl,  cannot  live  on  air  and  water  only,  but  require 
to  be  fed  also  with  organic  matter.  Some  feed  on  vege- 
table organic  matter  and  some  on  animal;  some  varieties 
require  the  organic  matter  to  be  living;  others  feed  only 
on  dead  matter. 

According  to  their  method  of  development,  these  vege- 
table micro-organisms  are  divided  into  groups: 

1.  Bacteria,    or    schizomycetes,    which    multiply    by 
fission,  a  simple  division  of  the  parent  cell  into  two.     The 
large  majority  of  disease-producing  germs  belong  to  this 
group. 

2.  Molds  or  Hyphomycetes. — These  multiply  by  sporu- 
lation,  a  process  somewhat  similar  to  seeding,  and  grow 
as  a  network  of  fine  filaments  from  which  other  threads 
project,  bearing  the  spores. 

3.  Yeasts    or    Saccharomycetes. — These   multiply   by 
budding,  the  protrusion  of  a  new  cell  from  the  parent  cell. 
TQ  the  activity  of  the  yeasts  are  due  the  familiar  phenom- 
ena of  fermentation,  causing  milk  to  sour,  bread  to  rise, 
the  conversion  of  sugar  into  alcohol,  etc. 

Few  of  the  molds  or  yeasts  are  disease-producing. 
Thrush,  and  some  varieties  of  skin  disease,  such  as  favus, 
are  caused  by  organisms  belonging  partly  to  the  mold  and 
partly  to  the  yeast  families.  In  very  rare  conditions 
mold  fungi  are  found  in  the  lung. 

Protozoa. — This  is  another  variety  of  micro-organisms, 
not  of  vegetable,  but  of  animal,  origin,  and  belonging 


BACTERIA  389 

to  the  lowest  known  form  of  animal  life.  Malaria, 
syphilis,  certain  forms  of  dysentery,  are  among  the  dis- 
eases due  to  protozoa. 

Micro-organisms  that  produce  disease  are  classed  as 
pathogenic;  those  that  do  not  produce  disease,  as  non- 
pathogenic.  To  the  activity  of  the  non-pathogenic  or- 
ganisms we  owe  many  of  the  beneficent  acts  of  nature. 
One  of  their  functions  is  the  breaking  up  of  complex  organ- 
isms into  simple  compounds — the  process  we  know  as 
decay.  Thus,  dead  organic  matter,  whether  vegetable  or 
animal,  is  converted  into  gases  and  water,  which  can  be 
used  as  food  by  plant  life,  the  plants  again,  in  their  turn, 
forming  food  for  animal  life. 

BACTERIA 

Investigation  proves  that  bacteria  exist  wherever 
animal  or  vegetable  life  has  existed.  They  are  found  in 
the  air,  in  water,  and  in  the  soil,  particularly  where  the 
soil  has  been  tilled,  and  may  be  present  on  any  tangible 
object.  Bacteria  are  constantly  present  in  some  parts  of 
the  body,  especially  the  mouth,  the  different  parts  of  the 
alimentary  tract,  and  the  skin.  They  are  not,  it  is  be- 
lieved, present,  in  a  normal  condition,  in  the  internal 
organs. 

In  order  to  grow,  bacteria  require  food,  moisture, 
warmth,  and  absence  of  light.  Some  require  oxygen  as 
supplied  by  the  air  of  the  atmosphere  in  order  to  develop; 
others  will  only  flourish  where  the  air  is  excluded.  Bac- 
teria that  require  air  are  called  aerobic;  those  that  require 
absence  of  air,  anaerobic;  bacteria  to  the  development 
of  which  one  condition  or  the  other  is  essential  are  spoken 
of  as  obligate  or  strict;  those  that  flourish  in  either  condition, 
as  facultative. 

The  food  of  bacteria  consists  of  organic  compounds, 
either  vegetable  or  animal.  Bacteria  that  feed  on  living 
tissue  are  known  as  parasites;  those  that  feed  on  dead 
organic  matter,  as  saprophytes.  In  feeding,  the  bacterial 
cell  has  the  power  of  selection,  by  which  it  attracts  those 
organic  cells  necessary  for  its  development  and  repels 


390      ELEMENTARY   BACTERIOLOGY   AND    IMMUMITY 

those  that  destroy  it.  The  attraction  of  one  cell  for  an- 
other is  called  positive  chemotaxis;  the  reverse,  negative 
chemotaxis. 

The  temperature  most  favorable  for  the  growth  of 
bacteria  is  the  temperature  of  the  living  body.  Since 
the  body  furnishes  the  right  temperature,  organic  food, 
moisture,  and  absence  of  light,  it  forms  an  ideal  soil 
for  the  development  of  bacteria. 


00  oS     f    a    ^f 

1  a       3      *         5  6 

Fig.  137. — Various  forms  of  bacteria:  1  and  2,  Round  and  oval 
micrococci;  3,  diplpcocci;  4,  tetracocci  or  tetrads;  5,  streptococci; 
6,  bacilli;  7,  bacilli  in  chains,  the  lower  showing  spore-formation; 
8,  bacilli  showing  spores,  forming  drumsticks  and  clostridia;  9  and 
10,  spirilla;  11,  spirochetae  (McFarland). 

Classification  by  Characteristics. — Certain  bacteria, 
by  their  activity,  produce  characteristic  phenomena, 
and  are  classified  according  to  these  characteristics: 

Chromogenic,  those  that  produce  color. 

Aerogenic,  those  that  produce  gas. 

Photogenic,  those  that  produce  phosphorescence. 

Zymogenic,  those  that  cause  fermentation. 


Fig.  138. — Diagram  illustrating  the  morphology  of  cocci :  a,  Coccus 
or  micrococcus;  6,  diplococcus;  c,  d,  streptococci;  e,f,  tetragenococci 
or  merismopedia ;  g,  h,  modes  of  division  of  cocci ;  i,  sarcinse :  j,  coccus 
with  flagella;  k,  staphylococci  (McFarland). 

Some  organisms  form  acids,  such  as  lactic  acid,  butyric 
acid,  etc.,  and  others,  alkalis,  of  which  the  principal  is 
ammonia.  This  is  often  an  important  aid  in  differentiat- 


BACTERIA 


391 


ing   between   bacteria   that   otherwise    closely   resemble 
each  other. 

That  part   of  bacteriology  which  treats  of  the  shape 
and  structure  of  bacteria  is"  called  morphology. 


Fig.  139. — Various  forms  of  micro-organisms:  1,  Streptococci;  2, 
staphylococci;  3.  diplococci;  4,  tetracocci;  5,  spirilla;  6,  bacilli;  7, 
bacilli  with  spores  (Paul). 

Classification  by  Shape. — According  to  their  shape,  bac- 
teria (schizomycetes}  are  divided  into  three  principal  groups : 


392       ELEMENTARY   BACTERIOLOGY   AND    IMMUNITY 

1.  The  spherical  or  coccus  (called  also  micrococcus). 

2.  The  rod-shaped  or  bacillus. 

3.  The  curved  or  spiral  or  spirillum. 

Micrococci. — The  cocci  may  be  round  or  oval.  In 
their  development  the  different  varieties  form  character- 
istic groupings,  according  to  which  they  are  classified: 

Monococci,  occurring  singly. 

Diplococci,  occurring  in  pairs. 

Tetrads,  occurring  in  groups  of  four. 

Sarcince,  occurring  in  groups  of  eight. 

Monococci  that  group  in  clusters  resembling  a  bunch 
of  grapes  are  called  staphylococci ;  those  grouped  so  as  to 
form  long  chains  are  called  streptococci.  A  mass  of  micro- 
cocci  in  a  jelly-like  matrix  is  called  a  zooglea. 

Bacilli.— The  different  bacilli  vary  considerably  in 
appearance,  but  all  retain  more  or  less  their  rod-like  shape; 


D  O  o 

d  e  f 

Fig.  140. — Diagram  illustrating  sporulation :  a,  Bacillus  inclosing 
a  small  oval  spore;  b,  drumstick-bacillus,  with  terminal  spore;  c, 
clostridium,  with  central  spore;  d,  free  spores;  e  and/,  bacilli  escap- 
ing from  spores  (McFarland). 

that  is  to  say,  they  are  always  longer  than  they  are  broad. 
Some  are  straight,  others  distinctly  oval;  in  some  the  ends 
are  square,  in  others,  round;  some  are  short  and  others  long. 
Bacilli  occur  as  separate  bodies,  or  grouped  end  to  end 
in  chains  or  threads.  In  the  latter,  light  transverse 
markings  may  be  seen,  marking  the  outline  of  the  in- 
dividual cells.  The  shape  of  a  bacillus  is  sometimes 
altered  by  the  presence  of  what  is  known  as  a  spore  (see 
below).  Where  a  spore  forms,  the  bacillus  bulges  slightly. 
Thus,  if  a  spore  forms  in  the  center,  it  gives  to  the  bacillus 
a  spindle  shape,  tapering  at  either  end;  a  spore  forming 
at  one  end  gives  to  the  bacillus  the  shape  of  a  drumstick. 
Unlike  the  coed,  bacilli  are  not  usually  subdivided  accord- 
ing to  their  form  or  groupings.  Many  are  named  after  the 
scientist  who  first  described  them,  as  the  Klebs-Loffler  bacil- 


BACTERIA  393 

lw;  others  are  named  from  the  disease  of  which  the  variety 
is  the  cause,  as  the  tubercle  bacillus,  the  typhoid  bacillus; 
and  others  again  from  the  substance  in  which  they  flourish, 
as  the  hay  bacillus,  the  potato  bacillus. 

Spirilla. — Spirilla  may  be  formed  of  one  single  curve, 
known  as  comma,  or  of  many  curves,  like  a  cork-screw; 
the  latter  are  frequently  called  spirochehe.  Spirilla 
forming  simple,  wave-like  lines  are  also  called  vibrios. 

Some  bacteria  possess  the  power  of  motility.  The 
micro-organism  is  provided  with  minute,  whip-like  proc- 
esses, known  as  flagellce,  by  the  vibration  of  which  it  can 
move  about  in  a  fluid  medium,  and  apparently  steer  itself. 
There  may  be  only  one  flagellum,  giving  to  the  cell  the 
appearance  of  a  tadpole,  or  they  may  be  distributed  like 
a  fringe,  either  all  round  the  cell  or  in  groups.  Micro- 
cocci  are  not,  as  a  rule,  motile;  several  bacilli  and  the 
majority  of  the  spirilla  have  this  property.  Under 
certain  conditions  the  power  of  motility  is  lost,  a  fact 
that  has  its  weight  in  certain  methods  of  diagnosis. 
(See  Widal  Reaction,  p.  401.)  This  power  of  motility 
is  an  independent  and  characteristic  property  of  the  cell, 
quite  different  from  certain  oscillating  movements,  which 
they  show  in  common  with  other  minute  particles  of 
matter  when  floating  in  a  fluid  medium. 

Reproduction. — All  bacteria,  as  has  been  said,  multiply 
by  fission,  a  simple  division  into  two  of  the  parent  cell. 
Multiplication  by  fission  is  termed  vegetative  reproduction. 
This  division  takes  place  with  great  rapidity — sometimes 
in  as  short  a  time  as  twenty  minutes.  As  is  seen,  espe- 
cially in  studying  the  micrococci,  in  dividing,  bacteria 
show  a  tendency  to  form  characteristic  groupings  and  to 
adhere  in  pairs,  fours,  or  eights,  or  in  the  form  of  clusters, 
chains,  or  threads. 

In  certain  of  the  bacilli  a  second  method  of  reproduc- 
tion sometimes  occurs.  In  the  bacillus  a  peculiar  bright, 
light  spot  is  observed,  generally,  but  not  invariably,  about 
the  center.  This  is  the  spore;  it  bears  to  the  bacillus 
the  relation  a  seed  has  to  a  plant,  and  will,  in  favorable 
conditions,  germinate  and  develop  into  an  ordinary  bacil- 
lus, and  proceed  to  multiply  by  fission  in  the  usual  way. 


394      ELEMENTARY   BACTERIOLOGY   AND   IMMUNITY 

Spores  are  very  much  more  difficult  to  destroy  than  the 
ordinary  bacteria,  owing  to  the  highly  resistant  capsule 
in  which  they  are  inclosed.  Means  for  disinfection  and 
sterilization  which  destroy  all  other  forms  of  bacteria  are 
ineffectual  with  spores.  The  recognition  of  spore  forma- 
tion in  certain  bacteria  is,  therefore,  extremely  important. 
Fortunately,  in  few  of  the  known  pathogenic  bacteria 
does  spore  formation  occur.  Two  known  to  possess  this 
property  are  the  anthrax  and  the  tetanus  bacilli.  The 
bacilli  of  tuberculosis  and  of  leprosy  are  described  as 
doubtful  instances  in  which  the  non-existence  of  spores 
has  not  been  proved. 

PROTOZOA 

The  protozoa,  being  an  animal  micro-organism  and  not 
of  vegetable  origin,  reproduces  in  a  totally  different 
manner.  They  resemble  a  very  elementary  form  of  ani- 
mal life,  found  in  swamps  and  stagnant  water.  Recent 
research  has  brought  to  light  a  curious  fact  in  the  life- 
history  of  many  of  the  pathogenic  protozoa  which  has 
revolutionized  the  methods  of  prevention  of  the  diseases 
caused  by  these  organisms.  Part  of  the  development  of 
the  protozoa  takes  place  in  man  and  part  in  the  body  of 
an  insect,  called  in  this  respect  the  host.  The  parasite 
is  sucked  from  the  blood  of  man  by  the  bite  of  the  insect, 
and  in  the  body  of  the  insect  only  undergoes  sex  develop- 
ment, without  which  it  remains  sterile,  and  gradually 
disintegrates.  The  infection,  it  is  considered,  is  trans- 
mitted only  through  the  bite  of  the  host. 

Transmission  by  Mosquitos. — A  species  of  mosquito, 
the  anopheles,  acts  as  the  host  to  the  malarial  parasite 
(plasmodium  or  hematozoon  malarice),  and  the  disease  is 
transmitted  by  its  bite.  A  second  mosquito,  the  stego- 
myia,  is  considered  in  the  same  way  to  transmit  the  in- 
fection of  yellow  fever,  and  investigation  at  the  present 
day  points  to  the  tsetse  fly  as  the  carrier  of  the  tropical 
disease  known  as  sleeping-sickness.  Certain  flies  and 
cattle-tick  are  similarly  the  source  of  certain  diseases 
affecting  animals. 

Size. — The  microscopic  minuteness  of  the  above  or- 


CESTODES — NEMATODES  395 

ganisms  is  difficult  to  realize.  To  measure  them,  a  special 
measure,  the  micromillimeter,  or  micron,  is  used,  the  symbol 
of  which  is  the  Greek  letter  n.  One  micron  equals  the 
thousandth  part  of  a  millimeter,  or  2517000  Par^  °f  an  inch. 
Thus,  if  a  bacillus  measures  in  length  one  micron,  254,000, 
placed  end  to  end,  will  measure  only  one  inch.  Some 
bacilli  measure  less  than  one  micron. 

CESTODES— NEMATODES 

Other  parasites  which  infest  the  human  body  are  not 
protozoa,  but  may  be  briefly  mentioned.  Such  are  the 
cestodes,  or  tapeworms,  and  the  nematodes,  or  round- 
worms,  which  gain  entrance  to  the  body  through  food  or 
drinking-water  containing  the  larvae  of  these  parasites. 
For  the  development  of  many  of  them  an  intermediary 
host  is  necessary,  such  as  the  hog,  the  ox,  or  fish.  By 
these  animals  the  eggs  are  ingested  and  the  flesh  becomes 
gradually  infiltrated  with  the  larvae  (measly  meat).  The 
larvae  consumed  by  man  in  such  meat  lodge  in  the  in- 
testine, and  there  develop  into  the  different  varieties  of 
tapeworm.  Another  cestode  has  as  its  host  the  dog. 
The  eggs  gain  entrance  in  drinking-water  or  on  cress  or 
other  plants  grown  in  the  water  and  eaten  raw,  and  de- 
velop in  man,  usually  in  the  liver,  where  they  grow  and 
form  numerous  cysts,  varying  in  size  from  a  head  to  a 
pigeon's  egg  (hydatid  cysts). 

Hookworm. — Among  the  nematodes  are  two  important 
worms  that  cause  serious  illness  when  developed  in  man. 
One,  the  hookworm  (Ankylostomum  duodenale),  develops 
in  the  small  intestine.  It  is  a  small  worm,  about  half  an 
inch  in  length,  with  a  hook-like  head,  by  which  it  attaches 
itself  to  the  walls  of  the  small  intestine.  It  causes  an 
intense,  persistent  anemia,  from  which  recovery  is  possible 
only  if  the  worm  can  be  expelled. 

The  Filaria  sanguinis  hominis  is  another  which  develops 
in  the  lymphatics.  The  embryos  are  found  in  the  blood, 
it  is  said,  only  at  night  or  during  the  hours  of  sleep.  In 
time  the  worms  cause  occlusion  of  the  lymphatics,  and  are 
the  origin  of  a  group  of  diseases  arising  from  this  condi- 
tion, of  which  elephantiasis  is  one. 


396      ELEMENTARY    BACTERIOLOGY   AND    IMMUNITY 

Both  these  worms  are  taken  into  the  system  in  drinking- 
water.  It  is  considered  that  the  embryo  of  the  filaria 
sanguinis  hominis  is  taken  from  man  to  the  water  by  the 
mosquito,  another  instance  of  an  insect  as  a  medium  of 
infection. 

Pin-worm. — Other  varieties  of  nematodes  are  the  pin- 
worm,  common  in  children,  the  earth-worm,  and  the  small 
worm  peculiar  to  the  hog,  and  found  in  "  measly  pork," 
which  causes  trichiniasis  when  developed  in  man. 

EXAMINATION  OF  BACTERIA 

Micro-organisms  are  examined  under  the  microscope, 
both  in  a  stained  or  an  unstained  condition  (see  below), 
and  either  alive  or  dead. 

The  Microscope. — The  principal  parts  of  the  microscope 
are  as  follows  (Fig.  141) : 

Eye-piece,  or  ocular. 

Draw-tube. 

Tube. 

Objectives  with  nose-piece. 

Stage. 

Substage. 

The  coarse  adjustment. 

The  fine  adjustment. 

Adjustment  of  substage. 

The  reflector. 

The  iris  diaphragm. 

The  base. 

The  base  supports  a  short  pillar,  to  which  the  micro- 
scope proper  is  attached. 

The  ocular  and  the  objective  are  both  fitted  with  lenses, 
thus  forming  a  compound  microscope;  a  single  magnifying 
lens  is  known  as  a  simple  microscope.  Usually  there  are 
three  objectives  of  different  magnifying  power,  used  at 
different  distances  from  the  object  under  examination. 
They  are  frequently  named  according  to  the  focal  distance. 
Thus,  a  *>-inch  objective  is  one  focused  half  an  inch  above 
the  object  to  be  examined;  the  measurement  has  no  refer- 
ence to  the  size  of  the  objective. 

The  terms  high  power  and  low  power  are  employed  to 


EXAMINATION    OF    BACTERIA 


397 


denote  the  magnification,   which   depends   both  on  the 
ocular  and  the  objective. 

The  stage  has  an  opening  in  the  middle  for  the  admis- 
sion of  light,  directly  over  which  is  placed  the  specimen  for 
examination  on  a  glass 
slide. 

Below  the  stage  is  the 
iris  diaphragm,  a  circular 
shutter,  by  opening  and 
closing  which  the  area 
of  light  may  be  enlarged 
or  decreased. 

Where  an  intense  il- 
lumination is  desired,  an 
arrangement  of  lenses 
known  as  the  Abbe  con- 
denser is  attached  below 
the  stage  opening.  The 
condenser  focuses  the 
light  from  the  reflector, 
and  throws  an  intense 
light  on  a  small  area. 
It  is  specially  required 
when  specimens  are  ex- 
amined under  the  oil- 
immersion  lens.  The 
oil-immersion  lens  is 
used  where  a  very  high 
power  of  magnification 
is  desired.  The  lower 
surface  of  a  high-power 
objective  (^.j)  is  im- 
mersed in  a  drop  of 
cedar- wood  oil  placed 
on  the  cover-glass,  be- 
low which  is  the  object  for  examination.  A  layer  of  oil 
is  then  formed  between  the  objective  and  the  object. 
The  oil  prevents  the  dispersion  of  light  and  acts  as  a  third 
lens,  increasing  the  magnifying  power  of  the  microscope. 

The  object  for  examination  in  position,  the  objective  is 


Fig.  141. — The  microscope:  1,  Eye- 
piece; 2,  draw-tube; '3,  main  tube;  4, 
nose-piece  with  objectives  attached; 
5,  objective  in  position;  6,  stage;  7, 
substage;  X,  adjustment  of  sub- 
stage;  9,  reflector;  10,  coarse  adjust- 
ment; 11,  fine  adjustment. 


398      ELEMENTAEY  BACTERIOLOGY   AND    IMMUNITY 

lowered  close  to  the  object,  without  touching  it,  by  the 
coarse  adjustment;  the  tube  is  then  slowly  raised  until  the 
picture  comes  into  view,  when  it  is  focused  finally  by  the 
fine  adjustment. 

Before  being  shown  specimens  under  the  microscope, 
pupils  should  be  carefully  taught  the  simple  manipulation 
of  the  different  parts  of  a  microscope  and  the  purpose  of 
each.  Every  part  of  a  microscope  is  an  expensive  item, 
and  more  or  less  easily  destroyed  by  careless  handling, 
objectives  in  particular  being  readily  spoilt  by  scratching. 

Examining  Bacteria. — For  examining  bacteria  when 
alive,  what  is  known  as  the  hanging  drop  is  used;  for  dead 
bacteria,  the  smear. 

PREPARATION  OF  SPECIMENS  FOR  EXAMINATION 

Smears.— In  lifting  the  material  for  examination  a  fine 
platinum  wire  is  used,  mounted  on  a  glass  rod.  The  wire 
may  be  straight,  or,  more  frequently,  the  end  is  twisted 
into  a  small  loop,  from  which  the  instrument  has  received 
the  name  Oese  (German  for  loop}.  The  wire  is  sterilized 
by  being  brought  to  a  red  heat  over  a  clean  flame  (alcohol 
lamp  or  Bunsen  burner),  and  must  then  be  allowed  to  cool 
before  using.  After  use  the  wire  must  again  be  sterilized 
in  the  same  manner,  in  order  completely  to  destroy  any 
organic  substances  still  adhering. 

The  specimen  for  examination  is  spread  in  a  thin  smear, 
in  the  center  of  a  small  piece  of  fine  glass  called  a  cover- 
glass.  The  glass  must  be  absolutely  clean,  sterile,  and 
free  from  scratches.  If  the  specimen  is  thick  and  tena- 
cious, it  may  be  diluted  by  placing  first  a  drop  of  distilled 
water  on  the  cover-glass.  A  thin,  even  film  is  obtained 
by  pressing  a  second  cover-glass  down  on  the  first,  and 
separating  them  by  sliding  the  two  surfaces  smoothly  one 
over  the  other.  The  smear  is  exposed  to  the  air  for  a  few 
moments  to  allow  it  to  dry,  or  the  moisture  may  be  re- 
moved by  blotting:  it  is  then  "fixed,"  usually  by  passing 
the  cover-glass  three  times  slowly  through  a  clean  flame. 
The  smear  is  then  ready  for  staining. 

Staining. — Weigert  and  Ehrlich,  two  German  scientists, 
introduced,  about  1877,  a  method  by  which  micro-organ- 


PREPARATION   OF   SPECIMENS   FOR   EXAMINATION      399 

isms  in  prepared  specimens  can  be  stained  or  colored 
without,  at  the  same  time,  coloring  the  medium  in  which 
the  bacteria  are  found.  Certain  colors  derived  from  coal- 
tar  products,  and  known  loosely  as  anilin  dyes,  have, 
they  demonstrated,  an  affinity  for  bacteria  and  for  the 
nuclei  of  tissues.  Bacteria  stained  by  their  dyes  stand 
out  clearly  from  the  background,  and  are  much  more 
readily  examined  than  as  the  transparent,  colorless,  ill- 
defined  bodies  they  appear  under  the  microscope  in  an 
unstained  condition.  Other  anilin  dyes,  again,  have  no 
affinity  for  bacteria,  but  stain  tissue  diffusely,  and  serve, 
therefore,  as  contrast  stains.  The  anilin  dyes  in  use  in 
bacteriology  are  classified  as — (a)  acid  and  (6)  basic  stains. 
The  basic  stains  are  used  to  stain  bacteria  and  the  nuclei 
of  tissue;  the  most  commonly  used  are  fuchsin,  gentian- 
violet,  and  methylene-blue.  The  acid  stains  are  used 
chiefly  to  stain  tissue-cells  and  as  contrast  stains;  the 
principal  are  eosin,  picric  acid,  and  acid  fuchsin. 

There  are  numerous  methods  of  staining  specimens. 
The  following  is  one  of  the  simplest: 

1.  Fill  a  small  shallow  dish  with  a  weak  solution  of  one 
of  the  basic  dyes  in  distilled  water. 

2.  Immerse  the  cover-glass  on  which  the  smear  has  been 
made  as  above  for  thirty  seconds. 

3.  Remove  and  wash  thoroughly  in  distilled  water.     The 
bacteria  may  be  shown  with  greater  distinction  if,  on 
removal  from  the  stain  bath,  the  specimen  is  rinsed  in  a 
1  per  cent,  solution  of  acetic  acid  before  being  washed. 
The  specimen  may  now  be  examined  under  the  microscope 
or  it  may  be  mounted  permanently  on  a  glass  slide,  a  thin 
piece  of  clear  glass  about  three  inches  long  by  one  inch 
wide.     To  mount  a  specimen,  a  drop  of  Canada  balsam  is 
allowed  to  fall  in  the  center  of  the  smear;  the  cover-glass 
is  then  placed  in  the  middle  of  the  slide,  the  smeared  side 
downward,  and  the  two  gently  pressed  together. 

Precautions. — If  pupil  nurses  are  taught  a  simple 
process  of  staining,  the  need  for  care  in  handling  the 
specimens  must  be  constantly  emphasized.  The  cover- 
glasses  and  slides  must  be  handled  throughout  with  forceps; 
the  oese  must  be  sterilized  by  bringing  to  red  heat  im- 


400      ELEMENTARY    BACTERIOLOGY   AND    IMMUNITY 

mediately  after  use,  and  before  being  laid  down;  blotting- 
paper  used  must  be  instantly  burned;  the  hands  must  be 
"sterilized "  before  the  process  is  begun,  to  prevent 
contamination  of  the  specimen,  and  immediately  it  is 
over  to  remove  any  bacteria  that  might  accidentally 
adhere  to  the  hands.  No  one  should  touch  a  specimen 
in  preparation,  however  carefully,  if  there  is  the  smallest 
scratch  or  abrasion  uncovered  on  the  hands. 

Gabbett's  Method  for  Tubercle  Bacilli. — It  is  frequently 
the  custom  to  teach  pupil  nurses  a  simple  method  of  stain- 
ing tubercle  bacilli  found  in  sputum.  The  method  known 
as  Gabbett's  method  is  generally  used,  on  account  of  its 
convenience.  The  procedure  is  as  follows: 

Required: 

1.  ZiehVs  carbol-fuchsin  solution: 

Fuchsin 1  gm. 

Carbolic  acid  (pure) 5  c.c. 

Alcohol 10  c.c. 

Water 100  c.c. 

2.  Gabbett's  solution: 

Methylene-blue 2  gm. 

Sulphuric  acid 25  c.c. 

Water 75  c.c. 

The  smear  being  made  as  described  above — "  1.  Cover 
the  specimen  with  Ziehl's  carbol-fuchsin  solution  and  hold 
the  cover-glass  over  the  flame  for  a  few  minutes  at  such 
a  distance  that  steam  is  formed. 

"  2.  Wash  off  the  excess  of  stain  in  water. 

"3.  Counterstain  by  treating  the  preparation  for 
thirty  seconds  with  Gabbett's  solution. 

"  4.  Again  wash  in  water,  dry,  and  mount  in  Canada 
balsam. 

"  The  tubercle  bacilli  will  appear  as  red  rods  in  a  blue 
field  "  ("  Manual  of  the  Practice  of  Medicine,"  A.  A. 
Stevens). 

The  method  of  thus  demonstrating  tubercle  bacilli 
(Plate  VIII)  rests  on  the  principle  that  "after  adding  to 
solutions  of  anilin  dyes  certain  substances,  such  as  car- 
bolic acid,  .  .  .  the  tuberculosis  bacillus  is  stained  with 


PLATE  VIII 


Tubercle  bacilli  in  urinary  sediment;  X  800  (Oe;den), 


PREPARATION   OF   SPECIMENS   FOR   EXAMINATION      401 

great  intensity  and  gives  up  its  stain  with  difficulty. 
Solutions  of  acids  will  remove  the  stain  from  all  parts  of 
the  preparation  except  from  the  tuberculosis  bacilli, 
which  retain  the  dye,  having  once  acquired  it  "  ("  Manual 
of  Bacteriology,"  H.  U.  Williams). 

The  Hanging  Drop.— When  it  is  desirable  to  examine 
living  bacteria,  a  special  slide  is  used  which  has  a  small 
cell  or  depression  in  the  center,  ground  out  of  the  thick- 
ness of  the  glass.  For  such  an  examination  the  bacteria 
must  be  in  a  fluid  media.  If  the  media  is  solid,  it  is  lique- 
fied by  the  addition  of  a  drop  of  bouillon  or  sterile  distilled 
water.  The  drop  for  examination  is  placed  on  a  cover- 
glass,  which  is  then  laid,  smeared  side  downward,  exactly 
over  the  small  concavity,  thus  forming  a  tiny  sealed 


Fig.  142. — The   "  hanging  drop "   seen  from  above  and  in  profile 

(McFarland). 

chamber.  Vaselin  smeared  on  the  slide  round  the  edge 
of  the  depression  serves  to  keep  the  cover-glass  in  place 
and  to  exclude  air.  In  this  hanging  drop,  as  it  is  called,  the 
movements  of  bacteria,  their  development  and  multipli- 
cation, can  be  observed  under  the  microscope. 

Widal  Reaction. — One  of  the  important  phenomena 
studied  by  the  hanging  drop  is  the  so-called  Widal  or 
serum  reaction  of  the  typhoid  bacillus  when  brought  in 
contact  with  a  drop  of  blood  from  a  patient  suffering  with 
typhoid  fever. 

The  typhoid  bacillus  is  one  of  those  that  possess  the 
power  of  motility,  or  independent  movement,  described 
above.  If  a  fresh  culture  of  the  bacillus  is  mixed  with  a 
drop  of  blood  from  a  typhoid  patient,  the  bacilli  are 

26 


402      ELEMENTARY   BACTERIOLOGY   AND    IMMUNITY 

observed  to  lose  their  motility  and  to  form  together  in 
masses  (agglutination). 

To  make  the  test,  a  drop  of  blood  is  taken  on  a  piece 
of  unglazed  paper  or  a  sterile  glass  slide.  This  is  diluted 
with  water,  bouillon,  or  salt  solution,  and  mixed  with  a 
fresh  bouillon  culture  of  the  typhoid  bacillus,  in  the  pro- 
portion of  about  1  in  40.  The  specimen  is  placed  on  a 
cover-glass  and  examined  as  just  described. 


Fig.  143. — Application  of  the  serum-reaction  to  typhoid  bacilli: 
A  shows  the  distribution  of  the  bacilli  before  the  reaction;  B  shows 
clumping  of  the  motionless  bacilli  after  mixture  with  the  serum  of  a 
case  of  typhoid  fever  (Williams).  (Diagrammatic.) 

This  peculiarity  in  the  blood  of  typhoid  patients  does 
not  occur  before  the  second  week  of  the  disease,  and  may 
persist  long  after  recovery. 


CULTURE  OF  BACTERIA 

In  order  to  study  bacteria,  it  was  found  necessary  to 
separate  the  different  varieties,  not  only  from  each  other, 
but  from  all  other  organic  matter  (matter,  that  is,  of  cell 
construction),  and  to  cultivate  them  artificially  by  placing 
them  in  media  that  furnish  the  proper  conditions  for  their 
development. 

Culture-media. — The  first  culture-media  were  fluids, 
broths  made  from  meat  or  vegetables,  and  contained  in 


CULTURE   OF   BACTERIA 


403 


glass  flasks.  As  media  they  were,  however,  imperfect; 
all  forms  of  microscopic  life  spread  quickly  through  the 
fluid  and  were  difficult  to  isolate  or  differentiate.  By 
boiling  the  broths  before  introducing  the  material  under 
examination  a  good  deal  of  micro-organismic  life  was  elim- 
inated, and  examination  was  further  facilitated  by  dilu- 
tion through  several  flasks  of  carefully  prepared  and 
sterilized  bouillon.  Thus  the  material  from  which  the 
bacteria  were  to  be  cultivated  would  be  stirred  into  one 
flask,  a  small  amount  would  then  be  taken  from  the  first 
flask  and  introduced  into  a  second,  and  the  process  re- 
peated through  several  others.  The  highly  diluted 
specimen  thus  obtained  was,  when  developed,  much 
easier  to  examine  than  one  crowded  with  micro-organisms. 
Still  the  method  was  baffling  and  imperfect. 

In  1881  Koch,  a  German  scientist,  and,  after   Louis 
Pasteur,  probably  the  most  universally  famous  of  bac- 


Fig.  144. — Petri  dish  for  making  plate  cultures  (McFarland). 

teriologists,  introduced  the  method  known  as  plating  and 
the  employment  of  solid  culture-media,  which  he  obtained 
by  mixing  the  bouillon  with  gelatin.  Koch  had  observed 
that  micro-organisms  growing  on  solid  bodies,  such  as  the 
potato,  grew  in  separate  colonies,  and  did  not  become 
confluent,  as  when  developed  in  fluid  media.  In  plating, 
three  tubes  of  gelatin-bouillon  are  used,  at  a  temperature 
which  will  keep  the  gelatin  liquid.  The  infected  matter 
is  introduced  into  the  first  tube  on  a  sterile  oese.  Three 
loopfuls  are  then  taken  from  the  first  tube  and  mixed  with 
the  second,  and  three  again  from  the  second  to  the  third. 
Each  tubeful  is  then  poured  into  a  separate  flat  glass  dish, 
called  a  Petri  dish,  and  covered  with  a  closely  fitted 
glass  cover.  On  cooling,  the  gelatin  solidifies  and  serves 
to  keep  the  bacteria  stationary  and  separate  from  one 


404       ELEMENTARY  BACTERIOLOGY   AND   IMMUNITY 


another.  As  the  bacteria  develop,  which  they  do  in 
from  one  to  two  days,  each  organism  develops  its  own 
species  in  an  area  more  or  less  isolated,  forming  what  is 
known  as  a  colony.  In  the  third  and  most  highly  diluted 
specimen  the  colonies  are  fewer  and  more  isolated  than 
in  the  other  two.  A  culture  obtained  in  this  way  is 
known  as  a  pure  culture,  of  which  the  definition  is  that  it  is 
"  one  variety  of  one  organism." 

The  advantage  gained  in  examining  bacteria  developed 
by  this  method  is  obvious:    its  introduction  gave  an  im 


Fig.  145. — Instruments  for  making  a  culture:  1,  Alcohol  lamp; 
2,  thumb  forceps;  3,  sterile  swabs;  4,  culture-tubes;  5,  platinum 
needle  (Morrow). 

mense  impetus  to  the  study  of  bacteria,  and  especially 
to  the  discovery  of  the  specific  organisms  which  now  were 
quickly  coming  to  be  recognized  as  the  cause  of  different 
diseases.  Simple  and  practical  though  these  modifica- 
tions of  existing  methods  by  Koch  appear,  they  are  con- 
sidered by  bacteriologists  to  have  had  such  important 
results  that  Koch  is  usually  considered,  by  this  invention, 
to  have  made  the  most  important  of  any  one  contribution 
to  bacteriologic  research. 


CULTURE   OF   BACTERIA  405 

At  the  present  day  a  variety  of  culture-media  are  used 
in  the  development  of  bacteria.  Nutrient  bouillon  is  the 
most  commonly  used,  either  by  itself  or  as  a  basis  for  other 
culture-media.  It  is  made  of  freshly  expressed  beef-juice 
or  of  beef-extract,  to  either  of  which  are  added  peptone, 
common  salt,  and  a  proportion  of  water.  For  the  solid 
media  the  same  bouillon  is  used,  with  the  addition  of 
gelatin  or  agar-agar.  The  latter  is  a  jelly-like  sea- weed 
obtained  from  Japan.  It  is  valuable  in  laboratory  work, 


Fie;.    146. — Showing  the   method  of    taking  a   culture    from    the 
pharynx  (Morrow). 

as  it  liquefies  at  a  higher  temperature  than  ordinary  gelatin. 
Slices  of  raw  potato  are  also  used  as  solid  culture-media. 
Milk,  to  which  a  small  proportion  of  litmus  is  added,  and 
blood-serum  are  other  culture-media  in  frequent  use. 

"  Loffler's  blood-serum  "  is  made  of  three  parts  blood- 
serum  and  one  of  a  bouillon  containing  1  per  cent,  glucose. 
It  is  the  culture  usually  employed  to  develop  the  diph- 
theria bacillus. 


406      ELEMENTARY   BACTERIOLOGY   AND    IMMUNITY 

Many  modifications  of  the  above  are  used.  All  require 
the  most  careful  preparation  and  sterilization  in  order  to 
prevent  the  possibility  of  bacterial  contamination.  In 
their  preparation  the  possibility  of  spore  contamination 
must  be  borne  in  mind,  since  if  these  resistant  bodies 
should  develop,  the  media  would  be  spoiled.  To  prevent 
this  risk  in  the  preparation  of  culture-media,  sterilization 
is  usually  done  by  the  fractional  method  (p.  453). 

Taking  a  Culture. — It  is  frequently  a  nurse's  duty  to 
"  take  a  culture,"  as,  for  example,  from  a  patch  on  the 


Fig.  147. — The  method  of  making  a  smear  culture  (Morrow). 

throat  or  the  discharging  surface  of  a  wound.  For  the 
process,  the  following  are  required: 

An  oese,  or  tooth-pick  applicator,  mounted  in  cotton. 

An  alcohol  lamp. 

Two  test-tubes  containing  the  media  desired.  The 
test-tubes  are  stoppered  with  sterile  cotton.  The  oese 
must  be  sterilized  as  described  and  cooled  before  using; 
if  an  applicator  is  used,  it  must,  of  course,  be  strictly 
sterile. 

Taking  the  greatest  care  to  come  in  contact  with  no 
other  object,  the  oese  or  applicator  is  gently  touched  to 


INFECTION  407 

the  infected  spot  and  lightly  moved  over  the  surface;  the 
tube  containing  the  medium  is  then  opened,  and  the  ma- 
terial introduced.  If  a  fluid  culture-media  is  used,  the 
instrument  is  stirred  into  the  fluid.  When  the  medium  is 
solid,  about  a  third  of  the  tube  is  filled  in  such  a  manner 
as  to  form  a  long,  slanting  surface;  over  this  surfacs  the 
instrument  is  lightly  zigzagged  from  the  bottom  up, 
taking  care  not  to  break  the  surface.  The  cotton  stopper, 
which  must  be  held  in  the  fingers  and  kept  from  touching 
any  object,  is  then  set  alight  at  the  alcohol  flame,  allowed 
to  blaze  a  moment,  and  replaced.  The  oese  is  sterilized 
by  reheating;  a  wooden  applicator  should  be  burned  at 
once. 

INFECTION 

Pathogenic  bacteria  gain  entrance  to  the  body  through 
the  lungs,  the  alimentary  system,  or  the  broken  surface  of 
the  skin  or  mucous  membrane. 

When  they  gain  entrance  to  the  body  in  sufficient  force 
to  overcome  the  natural  resistance  of  the  body-cells,  symp- 
toms of  disease  result,  and  we  say  that  infection  has  taken 
place.  Infection  may  be  local,  as  in  an  abscess  or  infected 
wound,  or  systemic,  as  in  any  of  the  so-called  infectious 
diseases. 

The  bacteria  themselves  do  not  attack  and  destroy 
the  tissues,  but,  as  a  result  of  their  activity,  they  elaborate 
certain  poisonous  substances  loosely  classed  as  toxins. 
The  production  of  these  toxins  is  similar  to  the  production 
of  ferments  in  such  familiar  processes  as  the  souring  of 
milk,  the  fermentation  of  sugar,  etc. 

Three  varieties  of  these  poisonous  substances  are  recog- 
nized: 

Toxins. — Substances  excreted  by  bacteria,  said  to 
resemble  in  their  action  the  vegetable  alkaloids. 

Toxalbumins. — Protein  substances  produced  by  the 
action  of  bacterial  ferments  or  enzymes  on  albumin. 
Toxalbumins  have  been  obtained  from  cultures  of  a  num- 
ber of  infectious  diseases,  diphtheria,  tuberculosis,  ty- 
phoid fever,  etc. 

Ptomain. — An    alkaloid    substance    produced    by    the 


408      ELEMENTARY   BACTERIOLOGY   AND    IMMUNITY 

action  of  bacteria  on  dead  organic  material,  such  as 
oysters,  canned  meats,  milk,  etc.  Ptomairis  are  usually 
elaborated  during  putrefaction,  and  are,  in  consequence, 
sometimes  known  as  putrefactive  alkaloids. 

Contagious  Diseases. — All  diseases  which  are  the  result 
of  bacterial  invasion  are,  strictly  speaking,  infectious; 
that  is,  the  specific  disease  does  not  develop  unless  the 
human  being  is  actually  infected  with  the  specific  germ 
causing  this  one  disease.  By  the  laity  the  term  is  gener- 
ally loosely  used  to  describe  only  such  diseases  as  are 
communicable  by  either  direct  or  indirect  contact  from 
man  to  man,  which  is  misleading.  The  correct  term  for 
such  diseases  is  contagious.  While  all  contagious  diseases 
are  infectious,  many  infectious  diseases  are  contagious 
only  to  a  limited  extent,  as,  for  example,  pneumonia, 
and  others  not  at  all,  as,  for  example,  rheumatic  fever. 
Still  another  variety  we  have  seen  requires  the  interven- 
tion of  an  intermediary  host  to  be  conveyed  from  man  to 
man. 

Besides  the  general  effects  produced  on  the  system, 
bacteria,  as  a  rule,  have  an  affinity  for  special  organs  or 
parts  of  an  organ,  in  which  they  produce  lesions  charac- 
teristic of  the  disease.  Thus,  in  typhoid  fever  we  find 
certain  glands  in  the  lower  intestine  extensively  ulcerated; 
in  diphtheria,  a  characteristic  membrane  is  observed, 
usually  on  the  mucous  membrane  of  the  nose  and  throat; 
other  infections  are  characterized  by  skin  eruptions  or 
rashes.  The  toxin  produced  by  the  tetanus  bacillus  acts 
on  the  nervous  system,  producing  violent  muscular  con- 
tractions and  profound  prostration. 

Some  bacteria,  such  as  the  tubercle  bacillus,  attack  now 
one  group  of  body-cells,  now  another,  producing  in  the  proc- 
ess different  groups  of  symptoms.  Thus,  when  the  germ 
attacks  the  coverings  of  the  brain,  we  have  tubercular 
meningitis  with  cerebral  disturbances  as  the  prominent 
symptom.  If  the  same  germ,  however,  attacks  the  lungs, 
we  have  pronounced  pulmonary  symptoms,  while  the 
brain  remains  clear  and  undisturbed. 

That  certain  diseases  were  from  the  earliest  times  recog- 
nized as  contagious  we  know  from  writings  that  have  come 


INFECTION  409 

to  us  from  the  ancients.  They  also  recognized  that  the 
spread  of  such  infections  was  to  some  extent  controlled 
by  isolation  and  by  purification  of  the  effects  and  dwell- 
ings of  the  victims  by  fire  and  by  cleansing  with  water. 
In  such  an  ancient  writing  as  the  Odyssey  we  find 
reference  also  to  the  use  of  the  fumes  of  sulphur  for  such 
purpose. 

The  discovery  of  the  specific  organisms  that  produce 
disease,  with  the  manner  of  their  invasion  of  the  human 
structure,  and  the  channels  through  which  the  invasion 
is  effected,  are  the  result  of  research  covering  but  little 
more  than  the  last  half  century.  Of  the  many  brilliant 
men  to  whom  we  are  indebted  for  the  numerous  discoveries 
in  the  field  of  bacteriology,  none  is  so  famous  as  Louis 
Pasteur. 

Louis  Pasteur,  a  Frenchman,  born  in  1822,  from 
about  the  year  1862  until  his  death  in  1895  devoted  his 
time,  his  money,  and  wonderfully  brilliant  intellect  to 
bacterial  research,  especially  in  reference  to  the  nature, 
course,  and  prevention  of  infectious  diseases.  His  name 
is  universally  known  as  the  originator  of  the  method  of 
curing  rabies  by  inoculation.  In  the  scientific  world 
Louis  Pasteur  is  regarded,  on  account  of  the  methods  of 
observation  he  originated,  his  experiments,  and  the 
deductions  and  teaching  he  based  upon  the  results  ob- 
tained, as  the  father  of  all  discoveries  in  the  field  of 
bacteriology;  he  is  also  the  founder  of  the  first  school  on 
the  subject. 

Theory  of  Antisepsis. — The  discoveries  of  Pasteur  and 
his  school,  especially  on  the  nature  and  causes  of  fermenta- 
tion and  putrefaction,  were  followed  with  absorbing  in- 
terest by  the  medical  scientific  world,  but  probably  with 
but  a  faint  conception  of  the  enormous  benefit  to  human 
and  animal  life  which  was  to  be  the  practical  outcome  of 
their  work.  In  1867  an  English  surgeon,  Joseph  Lister, 
then  attached  to  Edinburgh  University,  and  later  to 
King's  College  Hospital,  London,  applying  the  teaching 
of  Louis  Pasteur  to  practical  medicine,  propounded  the 
theory  that  suppuration  in  wounds  was  a  process  closely 
allied  to  fermentation,  and  similarly  the  result  of  the 


410      ELEMENTARY    BACTERIOLOGY   AND    IMMUNITY 

activity  of  micro-organisms  which  have  gained  access  to 
the  living  tissues.  If,  therefore,  he  deduced,  a  wound 
could  be  protected  from  the  invasion  of  bacteria  (or  infec- 
tion), suppuration  would  not  occur.  From  the  basis  of 
this  deduction  has  been  built  up  the  entire  fabric  of 
modern  antiseptic  and  aseptic  methods  in  surgery,  which 
have  opened  out  to  the  surgeon  the  immense  field  of  enter- 
prise impossible  before.  A  few  years  later  (1872)  a 
German  scientist,  Klebs,  pointed  out  a  similar  origin  as 
the  cause  of  general  sepsis,  or  blood-poisoning,  which,  up 
to  this  time,  was  constantly  present  in  surgical  wards, 
and  a  similar  possibility  of  its  prevention. 

Koch's  Postulates. — In  the  earlier  years,  as  has  been 
already  noted,  the  imperfection  of  the  means  and  methods 
of  examination  stood  in  the  way  of  the  discovery,  differ- 
entiation, and  classification  of  the  various  organisms. 
After  the  introduction  of  the  methods  of  plating  and  stain- 
ing already  described,  and  with  the  improvements  of  the 
microscopic  lenses,  research  began  to  make  rapid  strides, 
and  many  of  the  specific  organisms  of  special  diseases  were 
discovered.  In  order  that  a  specific  organism  should  be 
recognized  as  the  sole  origin  of  a  disease,  Koch,  the 
German  scientist  already  mentioned,  formulated  certain 
rules  or  postulates  with  which,  it  is  at  the  present  day  held, 
the  micro-organism  must  strictly  comply: 

1.  The  organism  must    be   present   in  the  tissues  in 
every  case  of  the  disease,  and  in  no  other,  and  it  must  be 
found  in  sufficient  numbers  to  explain  the  lesions  of  the 
disease. 

2.  The  organism  taken  from  such  a  case  must  be  de- 
veloped in  "  pure  culture." 

3.  The    organism    developed   in    pure    culture    must, 
when  inoculated  in  a  healthy  animal,  produce  the  same 
disease. 

4.  The  same  organism  must  be  recaptured  from  the 
animal  so  inoculated  in  which  the  disease  has  been  repro- 
duced. 

Bacteria  which  have  fulfiled  these  conditions  are  con- 
sidered as  the  origin  of  the  special  disease  in  which  they 


INFECTION 


411 


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have  been  proved  to  comply  with  Koch's  postulates: 


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412      ELEMENTARY   BACTERIOLOGY   AND   IMMUNITY 

In  several  other  diseases,  presumably  due  to  micro- 
organic  invasion  and  classed  as  infectious,  the  specific 
bacteria  have  not  yet  been  isolated. 

Such  are: 

Scarlet  fever. 

Measles. 

German  measles. 

Mumps. 

Whooping-cough. 

Chicken-pox. 

Typhus  fever. 

Yellow  fever. 

Hydrophobia. 

The  majority  of  these  diseases  are  actively  contagious. 

Many  theories  are  advanced  to  explain  why  the  bac- 
teria of  these  diseases  have  so  far  baffled  research.  It  is 
suggested  that  the  methods  and  means  are  yet  imperfect, 
that  the  organisms  may  be  too  minute  to  be  detected, 
even  by  the  powerful  lenses  of  the  present  day,  or  that  the 
usual  processes  of  culture,  staining,  etc.,  may  actually 
destroy  or  render  them  invisible;  others  advance  that  the 
organisms  may  actually  be  dissolved  by  the  products  of 
their  own  activity.  Certain  organisms  suspected  of  being 
the  cause  of  a  specific  disease  have  failed  to  be  proved 
by  Koch's  cycle.  Such  is  the  case  of  the  micro-organism 
(a  protozoon)  discovered  and  reported  as  the  origin  of 
smallpox  by  Wm.  T.  Councilman,  of  Harvard,  in  1904. 

MODES   OF   TRANSMISSION 

The  germs  of  disease  are  conveyed  to  man,  in  the  large 
majority  of  cases,  by  the  air,  or,  more  correctly,  the  dust- 
particles  in  the  air,  and  by  water  or  food  contaminated 
by  impure  water.  Other  methods  are  by  direct  inocula- 
tion and  by  the  bite  of  an  insect  acting  as  host  to  the  germ. 

Air-borne  Diseases. — Diseases  carried  by  floating  dust 
are  classed  as  air-borne.  The  majority  invade  the 
respiratory  tract.  In  this  class  are  all  actively  contagious 
diseases: 

Scarlet  fever 

Measles. 


MODES   OF  TRANSMISSION  413 

German  measles. 

Chicken-pox. 

Mumps. 

Smallpox. 

Diphtheria. 

Tuberculosis. 

Typhus  fever. 

Cerebrospinal  meningitis. 

Epidemic  pneumonia. 

Grip. 

The  germ-laden  dust-particles  may  float  in  the  air  or 
may  settle  on  solid  articles  in  the  vicinity  of  the  patient, 
which  may  then  become  media  of  infection.  Substances 
which  absorb  contagion  in  this  way  or  by  direct  handling 
by  the  patients  are  called  fomites.  In  the  more  virulent 
infections,  especially  smallpox  and  scarlet  fever,  the 
germs  arc  retained  by  the  fomites  for  practically  in- 
definite periods.  Articles  actually  handled  by  the  patients, 
such  as  toys,  books,  and  work,  are  impossible  to  disin- 
fect with  any  certainty,  and  should  be  destroyed  after 
convalescence  or  given  for  the  use  of  patients  suffer- 
ing from  the  same  disease  in  hospitals  devoted  to  this 
purpose. 

The  germs  may  escape  into  the  air  in  several  ways. 

The  special  germs  causing  the  disease,  it  must  be  remem- 
bered, is  always  present  in  the  greatest  number  in  the 
lesions  of  the  disease. 

1.  When  lesions  are  present  in  any  part  of  the  respira- 
tory tract,  the  mouth,  throat,  nose,  or  lungs,  the  germs  are 
actually  breathed  into  the  air  and  adhere  readily  to 
floating  dust.  In  such  acts  as  sneezing,  coughing,  speak- 
ing, and  even  breathing,  under  some  circumstances,  the 
germ  may  be  transmitted  in  minute  drops  of  moisture 
which  remains  suspended  in  the  air  for  considerable 
periods.  Infection  by  this  means  is  known  as  droplet 
infection.  In  the  diseases  above  mentioned  many  are 
characterized  by  lesions  in  the  throat  or  air-passages. 
In  those  without  this  special  characterization,  especially 
typhus  fever,  meningitis,  and  smallpox,  the  germ  seems 
also  to  be  present  in  the  breath. 


414      ELEMENTARY    BACTERIOLOGY   AND   IMMUNITY 

2.  In  those  infectious  diseases  characterized  by  a  rash 
and  followed  by  desquamation,  the  germs  are  contained 
in  the   shed   particles  of  epithelium.     Minute   particles 
remain  floating  as  dust  in  the  air  or  settle  on  objects  in  the 
vicinity,  which  then  become  sources  of  contagion. 

3.  Where  the  lesions  of  the  disease  are  associated  with 
abnormal  secretions,  countless  numbers  of  the  germs  will 
be  found  present  in  the  discharges,  sputum,  etc.     As  long 
as  the  bacteria  remain  enmeshed  in  the  moist  substance 
they  are  not  in  a  position  to  do  harm,  and  may  readily 
be  destroyed   (see  Disinfection).     If,   however,  through 
lack  of  cleanliness,  the  discharges  are  allowed  to  dry, 
as,  for  example,  the  sputum  in  public  streets,  or  on  the 
hands,  sputum-cups,  or  clothing  of  patients  or  attendants, 
the  germs  are  set  free  and  carried  by  floating  dust. 

Water-borne  Diseases.— A  more  limited  number  of 
infectious  diseases  are  communicated  through  drinking- 
water,  contaminated  by  the  specific  bacteria  of  the  disease, 
and  are  classed  as  water-borne  diseases.  They  invade  the 
system  through  the  alimentary  tract.  Such  are: 

Cholera. 

Diarrhea  (certain  forms). 

Dysentery. 

Typhoid  fever. 

Food  may  also  be  contaminated  with  the  bacteria  of 
any  of  these  diseases  by  such  means  as  washing  vegetables 
consumed  in  a  raw  condition  with  contaminated  water,  by 
using  such  water  for  the  cleansing  of  vessels,  especially 
those  for  containing  milk,  or  by  diluting  milk  with  con- 
taminated water.  Food  may  also  be  infected  directly 
from  the  hands  of  patients  or  their  attendants  if  these 
are  not  kept  scrupulously  clean,  and  the  bacteria  prob- 
ably taken  into  the  system  in  this  way.  Infection  has 
also  been  conveyed  by  oysters  that  have  been  fed  on  a 
contaminated  water  supply. 

Water-borne  diseases  may  also  in  certain  conditions 
be  air-borne. 

The  lesions  in  this  class  of  infections  are  in  the  ali- 
mentary tract,  consequently  the  evacuations  are  loaded 
with  the  bacteria.  If  the  evacuations  are  left  exposed 


MODES   OF  TRANSMISSION  415 

and  not  immediately  disinfected,  the  bacteria  readily 
escape  into  the  surrounding  air  and  may  be  conveyed  on 
floating  dust.  The  smallest  stain  of  feces  on  linen  or 
vessel  should  be  regarded  as  an  active  colony  of  bacteria 
and  rigorously  disinfected. 

Some  air-borne  diseases  may  also  be  made  water-borne 
by  direct  contagion.  In  this  way  scarlet  fever  and  diph- 
theria have  frequently  been  spread  from  a  milk  supply 
where  the  milk  has  been  left  exposed  in  the  vicinity  of 
such  cases.  Milk,  it  will  be  remembered,  is  one  of  the 
media  in  which  bacteria  readily  grow. 

Whether  tuberculosis  is  conveyed  in  the  milk  or  flesh 
of  cattle  with  the  animal  variety  of  this  disease  is,  at  the 
present  day,  not  determined. 

A  group  of  infections  associated  with  surgical  condi- 
tions are  also  air-borne,  but  invade  the  system  through  the 
broken  surface  of  the  skin  or  mucous  membrane.  Such 
are: 

Erysipelas. 

Puerperal  fever. 

Septicemia. 

Pyemia. 

All  forms  of  septic  infection,  either  general  or  local. 

Instances  also  occur  where  the  germs  of  scarlet  fever, 
diphtheria,  or  smallpox  apparently  invade  the  system 
through  the  broken  surface.  This  is  demonstrated  in  the 
peculiar  susceptibility  of  patients  during  the  puerperium 
to  these  infections,  and  a  disposition  on  the  part  of  patients 
who  have  undergone  recent  operation  to  develop  a  mild 
form  of  scarlet  fever.  The  diphtheria  germ  has  also  been 
known  to  attack  the  broken  surface,  developing  the  char- 
acteristic membrane  on  the  surfaces  of  wounds,  and 
giving  rise,  at  the  same  time,  to  the  physical  symptoms 
that  accompany  an  attack  of  diphtheria. 

Infection  by  Inoculation. — Besides  the  air-borne  dis- 
eases which  invade  the  system  through  an  accidental 
break  in  the  continuity  of  the  surface  of  the  body  at  some 
point,  others  require  that  the  virus  containing  the  germ 
should  be  directly  inoculated  below  the  surface,  as  the 
snake,  by  its  bite,  introduces  its  venom  into  the  blood, 


416      ELEMENTARY  BACTERIOLOGY   AND   IMMUNITY 

The  principal  diseases  of  man  so  communicated  are: 

Tetanus. 

Rabies. 

Syphilis. 

Ophthalmia. 

Leprosy. 

Glanders. 

Cowpox,  or  vaccine. 

The  germ  of  tetanus  develops  in  the  absence  of  air; 
it  finds  a  favorable  condition  for  development  in  the  deep 
wounds  caused  by  puncture  or  by  gunshot  accidents;  it  is 
especially  to  be  guarded  against  in  wounds  that  are  con- 
taminated by  the  soil,  since  the  tetanus  germ  is  found  in 
the  soil. 

Rabies  is  introduced  by  the  bite  of  an  infected  animal; 
syphilis,  by  the  virus  coming  in  direct  contact  with  an 
abrased  surface;  ophthalmia,  in  like  manner,  through  an 
abrasion  of  the  conjunctiva;  leprosy,  glanders,  and  cowpox, 
the  two  latter  diseases  transmitted  to  man  from  cattle, 
are  usually  conveyed  through  abrasions  on  the  hands. 
It  is  considered  probable  that  bubonic  plague  also  invades 
the  system  by  inoculation,  as  well  as  by  the  respiratory 
and  alimentary  tracts. 

Tuberculosis,  though  most  commonly  conveyed  by  the 
air,  either  through  floating  dust  or  by  droplet  infection, 
may  also  be  transmitted  by  inoculation.  This  is  especially 
true  of  tuberculosis  attacking  the  skin,  as  in  lupus;  but 
should  be  borne  in  mind  in  working  with  laboratory 
specimens. 

As  has  already  been  noted,  certain  diseases  are  trans- 
mitted from  man  to  man  through  the  bite  of  an  insect 
acting  as  intermediary  host.  Such  are  malaria,  by  the 
anopheles  mosquito;  yellow  fever,  by  the  stegomyia  fas- 
ciata;  sleeping  sickness,  by  the  tsetse  fly. 

Recent  investigation  seems  to  show  that  bubonic  plague 
is  frequently  transmitted  by  the  bite  of  fleas  infesting 
rats  which  are  infected  with  the  plague  bacillus. 

Relapsing  fever,  a  disease  fast  disappearing  under 
improved  hygienic  conditions,  is  also  considered  to  be 
probably  conveyed  by  the  bite  of  an  insect,  and  the  same 


PROPHYLAXIS   OF  THE    INFECTIOUS   DISEASES       417 

may  be  true  of  other  infections  which  are  spread  by  filth 
and  overcrowding,  such  as  typhus  fever  or  jail  fever. 
How  far  domestic  insects,  flies,  bedbugs,  etc.,  may  be 
carriers  of  disease  is  still  a  moot  point.  Flies  may  cer- 
tainly be  the  means  of  infecting  milk  and  other  foods. 
We  know  how  readily  they  are  attracted  to  organic  matter. 
If,  through  lack  of  cleanliness,  flies  are  allowed  to  alight 
on  particles  of  feces,  sputum,  soiled  dressings,  and  similar 
sources  of  infection,  germs  may  readily  adhere  to  the 
legs  and  bodies  of  these  insects  and  be  conveyed  to  food 
left  exposed.  The  water-borne  diseases,  especially  ty- 
phoid fever,  are  peculiarly  apt  to  be  spread  in  this  way. 

PROPHYLAXIS  OF  THE  INFECTIOUS  DISEASES 

Modern  prophylaxis,  or  the  prevention  of  infectious 
diseases,  rests  on  a  recognition  of  the  sources  of  infection, 
and  on  the  use  of  hygienic  and  scientific  methods  for  the 
control  of  the  media  by  which  infection  is  spread. 

The  most  powerful  enemies  of  the  air-borne  infections 
are  fresh  air  and  sunlight.  The  air  of  a  sick-room,  if 
well  diluted  with  constantly  changing  fresh  air,  will  ob- 
viously contain  much  fewer  germs  than  if  the  room  is  kept 
closed  and  only  "  aired "  at  stated  intervals.  Direct 
sunlight  is  a  natural  germicide,  and  should  have  access 
to  every  corner  of  a  sick-room.  The  walls,  floors,  and 
furniture  of  a  room  constantly  used  as  a  sick-room  should 
be  chosen  with  hard,  non-absorbent  surfaces  and  kept 
scrupulously  free  from  dust;  draperies,  rugs,  and  up- 
holstered furniture  should  be  banished  or  be  entirely  of 
washable  materials,  as  should  also  be  the  clothing  of  those 
in  attendance  on  the  sick.  The  air  of  the  sick-room  should 
be  kept  free  from  contamination  from  such  sources  as 
uncovered  sputum-cups,  soiled  surgical  dressings,  or  bed- 
pans not  instantly  removed. 

The  prophylaxis  of  the  water-borne  infections  bears 
chiefly  on  the  insistence  of  a  pure  water  supply  and  the 
scrupulous  disinfection  of  all  excreta  in  these  cases.  (See 
Disinfection,  p.  466.)  If  there  is  any  doubt  on  the  subject 

27 


418      ELEMENTARY    BACTERIOLOGY   AND    IMMUNITY 

of  the  water-supply,  it  must  be  an  absolute  rule  that  only 
boiled  water  is  used  for  drinking,  for  washing  vegetables, 
and  for  cleansing  the  vessels  used  for  cooking  and  in  the 
serving  of  the  meals.  The  water-supply  of  districts  may 
be  directly  contaminated  from  infected  excreta  thrown 
without  thorough  disinfection  down  the  soil-pipes,  or 
from  excreta  deposited  on  the  surface  soil  or  carried  to 
cess-pools  in  the  vicinity  of  natural  wells.  Standing 
water,  such  as  the  water  of  wells,  if  once  contaminated, 
always  remains  so,  and  the  well  must,  therefore,  be 
closed. 

Food  should  be  screened  from  flies,  and  never  exposed 
in  the  neighborhood  of  lavatories;  milk  and  butter  should 
be  especially  kept  in  closed  cans  or  chests.  The  strictest 
care  must  be  taken  in  the  immediate  cleansing  of  the  hands 
after  doing  any  service  about  the  patient,  and  especially 
in  regard  to  the  removal  and  disinfection  of  the  excreta. 
The  vessels  used  should  be  closely  covered  for  removal  from 
the  bedside,  and  the  smallest  stain  of  fecal  matter  on  the 
linen  disinfected  at  once.  It  should  be  looked  upon  as 
essential  that  the  sick-room  should  be  screened  from  flies, 
and  vigilant  warfare  waged  against  bedbugs  and  other 
insects. 

In  those  air-borne  diseases  which  invade  the  system 
through  the  broken  surface  (see  above),  protection  lies  in 
never  exposing  a  wound  where  there  is  any  possibility  of 
these  germs  being  present  in  the  air.  Such  cases  may  be 
nursed  without  risk  of  contagion  in  a  medical  ward,  but 
are  a  fertile  source  of  infection  in  a  surgical  ward,  where 
wounds  are  exposed  for  dressing  or  treatment. 

The  spread  of  infection  where  inoculation  is  the  means 
of  transmission  should  be  easy  to  control;  nevertheless, 
the  sources  of  infection  require  to  be  recognized.  Rabies 
is  transmitted  only  by  the  bite  of  a  rabid  animal  (unless 
one  excepts  accidental  inoculation  in  laboratory  work). 
The  germ  of  tetanus  is  found  in  the  soil,  especially  in  soil 
contaminated  by  the  excreta  of  herbivorous  animals, 
such  as  may  be  found  round  farms  and  stables.  The 
germ  is  usually  introduced  at  the  time  of  injury,  but 
wounds  previously  clean  may  absorb  the  tetanus  germ  if 


PROPHYLAXIS   OF  THE    INFECTIOUS   DISEASES       419 

exposed  to  dirt  in  which  the  germ  is  present.  The  virus 
of  syphilis  is  contained  in  any  of  the  discharges  of  a 
syphilitic  patient.  Discharges  from  the  genito-urinary 
tract  or  the  nose,  and  ulcers  with  a  discharging  surface, 
are  common  manifestations  of  venereal  disease.  An  abra- 
sion on  the  hands  of  doctor  or  nurse  carelessly  brought  in 
contact  with  such  discharges  may  readily  be  the  means 
of  infecting  the  system  with  this  most  virulent  disease. 
Closets  and  vessels  used  by  patients  with  gonorrheal  dis- 
charge are  a  source  of  infection  unless  rigorously  disin- 
fected. The  virus  may  also  be  transmitted  to  a  third 
person  by  the  hands  of  the  attendant  or  by  instruments, 
especially  catheters,  laboratory  vessels,  or  linen,  which 
have  been  used  for  a  syphilitic  patient  and  imperfectly 
disinfected.  Ophthalmia  is  communicated  in  a  somewhat 
similar  way.  The  discharge,  in  this  instance,  must  come 
in  contact  with  the  conjunctiva.  The  eyelids  may  be 
rubbed  with  fingers  contaminated  with  the  discharge 
either  directly  or  indirectly  from  handling  infected  instru- 
ments, towels,  etc.  A  common  channel  for  the  spread  of 
ophthalmia,  especially  in  children's  wards,  is  the  apron- 
bibs  of  nurses  who  thoughtlessly  take  a  baby  with  oph- 
thalmia on  the  arm.  The  next  baby  taken  in  the  same 
position  runs  a  grave  risk  of  infection. 

The  infection  of  wounds  with  pus-producing  organisms 
(usually  a  variety  of  staphylococcus)  is  also  to  a  large 
extent  a  process  of  inoculation.  The  channel  is  most 
commonly  the  hands  of  the  operator  or  dresser,  and,  less 
frequently,  the  instruments,  lotions,  dressings,  ligatures, 
etc.,  used.  (See  Surgical  Technic,  Chap.  XIV.)  A  local 
abscess  following  the  administration  of  a  hypodermic 
injection,  and  an  infected  finger  from  contact  of  an  un- 
noticed scratch  with  an  infectious  discharge,  are  direct 
examples  of  pus  infection  by  inoculation. 

It  must  also  be  remembered  that  germs  not  usually 
transmitted  by  inoculation  may  also  be  introduced  into 
the  system  in  this  way.  Thus,  a  hypodermic  needle,  used, 
for  example,  on  a  diphtheria  case  and  imperfectly  steril- 
ized, may  inoculate  with  the  diphtheria  bacillus  a  second 
person  not  otherwise  exposed  to  the  contagion. 


420      ELEMENTARY   BACTERIOLOGY   AND   IMMUNITY 

When  we  realize  that  in  common  with  all  other  known 
forms  of  life  a  germ  can  only  spring  from  a  similar  germ 
already  existing,  we  can  understand  the  immense  import- 
ance of  intelligent  prophylaxis.  A  case  of  scarlet  fever, 
for  example,  can  no  more  occur  independently  than  a 
field  of  wheat  can  be  grown  without  seed.  Infectious 
illnesses  are  already  more  under  control  than  has  ever 
been  possible  before,  and  people  are  beginning  to  regard 
pure  air,  sunlight,  and  pure  water  not  as  luxuries,  but  as 
necessary  to  all  if  the  health  of  the  community  is  to  be 
maintained. 

In  the  transmission  of  infections  through  an  intermediary 
host  prophylaxis  lies  in  the  protection  of  man  from  the  bite 
of  the  insect  and  in  the  extermination  of  the  insect. 

The  special  insects  at  the  present  day  known  to  be  trans- 
mitters of  the  specific  diseases  are  peculiar  to  certain  dis- 
tricts. Persons  who  show  a  special  liability  to  malaria 
should  avoid  the  districts  where  the  anopheles  mosquito 
is  known  to  exist.  The  dwellings  in  these  localities  should 
be  carefully  screened,  and  vigilance  exerted  that  each 
insect  that  may  gain  admission  is  promptly  destroyed. 
Persons  should  remain  indoors  during  the  feeding  times 
of  the  mosquito,  especially  evening  and  early  morning. 
When  a  person  has  become  infected,  he  must  be  carefully 
protected  from  being  bitten,  since  it  is  only  from  his 
blood  that  the  mosquito  in  its  turn  becomes  infected. 
In  cases  of  yellow  fever  the  patient  is  at  once  isolated  in  a 
fly-screened  tent,  a  precaution  which,  as  soon  as  adopted, 
reduces  enormously  the  number  of  patients  in  an  epidemic 
of  this  disease.  The  insects  are  exterminated  by  destroy- 
ing their  breeding-grounds;  in  the  case  of  the  malarial 
mosquito  the  breeding-ground  is  the  stagnant  water  of 
swamps,  woodland  pools,  etc.,  or,  in  inhabited  districts, 
the  barrels  and  cisterns  in  which  water  is  collected. 
Thorough  drainage  in  many  districts,  such  as  the  fen  coun- 
tries of  England,  has  been  followed  by  total  extermination 
of  the  mosquito  and  complete  disappearance  of  the  disease. 
Pools  and  small  areas  of  stagnant  water  are  in  other  parts 
covered  with  coal-oil  and  thus  made  impossible  as  breed- 
ing-grounds. Wells,  water-barrels,  drinking-troughs,  reser- 


IMMUNITY  421 

voirs,  and  all  vessels  containing  standing  water  must  be 
kept  closely  covered  or  in  carefully  screened  inclosures. 

IMMUNITY 

All  persons  exposed  to  infection  do  not  necessarily 
succumb  to  disease.  This  is  due  to  two  conditions — 
first,  the  natural  resistance  of  the  body;  and,  second,  a 
condition  of  immunity,  either  natural  or  acquired. 

It  is  considered  that  the  chief  elements  of  resistance  to 
bacterial  invasion  are  found  in  the  blood:  in  those  white 
corpuscles,  or  phagocytes,  whose  function  it  is  to  seize  and 
destroy  foreign  bodies  gaining  access  to  the  body,  and  in 
the  blood-serum,  which  is  also  held  to  have  bactericidal 
properties.  Bacteria  are  also  eliminated  in  the  natural 
excreta  of  the  body,  especially  in  the  evacuations  of  the 
bowel.  A  further  protection  is  given  to  the  body,  it  is 
considered,  in  the  natural  secretions  which  cleanse  the  sur- 
face and  the  external  cavities  of  the  body,  ridding  them,  to 
some  extent,  of  invading  bacteria,  and  which,  if  not  ac- 
tively germicidal,  form  media  in  which  bacteria  do  not 
readily  develop;  such  are  the  sweat,  the  tears,  the  saliva, 
and  the  mucous  membrane  secretions.  The  hydrochloric 
acid  contained  in  the  gastric  juice  is  also  held  to  have 
germicidal  properties  toward  the  bacteria  of  the  water- 
borne  diseases. 

Certain  conditions  weaken  the  natural  resistance  of 
the  body  and  leave  it  a  prey  to  infection.  Such  are 
unhygienic  conditions,  overwork,  overstrain,  mental  or 
physical,  alcoholism,  starving,  exposure,  debilitating  or 
chronic  diseases,  such  as  kidney  disease,  diabetes,  etc., 
local  injuries,  serious  accidents,  and  other  conditions  that 
impair  the  general  health. 

In  surgical  work  sound  tissue  is  held  to  show  consider- 
ably more  resistance  to  bacterial  invasion  than  tissue  that 
has  been  injured  by  accident,  or  by  rough  handling  during 
an  operation. 

At  certain  times  the  bacteria  may  be  present  in  abnormal 
numbers,  as  during  epidemics,  and  the  natural  resistance 
may  be  overthrown  on  this  account. 

Natural  immunity  is  the  unbroken  resistance  exhibited 


422      ELEMENTARY   BACTERIOLOGY   AND   IMMUNITY 

by  a  race  or  a  species  to  certain  diseases.  Thus  the 
negro  is  proved  to  be  immune  to  yellow  fever;  the  dog  is 
immune  to  typhoid  fever,  the  common  infectious  fevers, 
and  other  diseases  of  man,  and  man,  on  the  other  hand, 
to  certain  diseases  of  the  lower  animals. 

Acquired  immunity  may  be  either  active  or  passive. 

By  active  immunity  we  mean  an  immunity  that  is  the  re- 
sult of  previous  bacterial  activity  in  the  body  of  the  patient. 

This  may  be  attained  in  three  different  ways: 

1.  By  an  attack  of  the  disease. 

2.  By  vaccination. 

3.  By  certain  forms  of  inoculation. 

Passive  immunity  is  brought  about  by  the  injection  of 
antitoxins. 

We  know  that  if  recovery  is  to  take  place  from  an  in- 
fectious malady,  at  a  certain  point  in  the  disease  there 
comes  a  turning-point  after  which  there  are  no  fresh 
manifestations  of  bacterial  activity.  The  symptoms  of 
the  disease  subside,  and  in  a  short  time  convalescence 
follows.  In  some  infections  the  turning-point  is  abrupt, 
and  we  say  that  the  disease  ends  with  a  crisis;  in  others 
the  improvement  takes  place  more  slowly,  and  we  use  the 
term  lysis.  In  many  diseases  we  can  tell  to  within  a  few 
hours  when  the  crisis  will  take  place  or  the  lysis  begin. 
Not  only  is  the  further  development  of  the  disease  arrested, 
but  the  body  for  a  time  is  impervious  to  fresh  infection 
from  the  same  disease.  Thus  a  patient  just  recovered  from 
scarlet  fever  can  mix  freely  with  patients  at  the  most  con- 
tagious stage  of  that  disease,  without  contracting  the  dis- 
ease a  second  time.  As  regards  scarlet  fever,  they  are  in  a 
state  of  acquired  immunity. 

In  many  diseases  the  acquired  immunity  conferred  by 
one  attack  lasts  through  life.  Such  are: 

Scarlet  fever. 

Chicken-pox. 

Mumps. 

German  measles. 

Typhoid  fever. 

Typhus  fever.     ^ 

Yellow  fever. 


IMMUNITY  423 

Second  attacks  of  these  infectious  diseases  are  un- 
common. Second  attacks  of  measles  and  whooping- 
cough  occur  somewhat  frequently,  and  in  small-pox  also 
second  attacks  are  known.  In  typhoid  fever  second  at- 
tacks do  occasionally  occur,  but  are  not  considered  the 
rule;  a  form  of  reinfection  during  the  early  stage  of  con- 
valescence is,  however,  frequently  observed.  An  error 
of  diet,  or  conditions  that  exhaust  the  vitality  of  the  pa- 
tient, such  as  exertion,  are  commonly  the  predisposing 
causes.  To  this  form  of  reinfection  the  term  relapse  is 
applied. 

In  other  infections  the  immunity  conferred  is  only 
temporary,  and  one  attack  of  the  disease  appears  to  pre- 
dispose to  repeated  attacks.  Such  are: 

Erysipelas. 

Malaria. 

Rheumatic  fever. 

Diphtheria. 

Grip. 

Pneumonia. 

Vaccination. — A  very  mild  attack  of  a  disease  confers 
immunity  as  completely  as  a  severe  attack.  This  prin- 
ciple was  for  long  applied  practically  in  the  East  of 
Europe  in  the  treatment  of  smallpox,  a  disease  in  its  severe 
form  frequently  fatal.  It  was  the  custom  to  puncture  the 
skin  of  persons  likely  to  be  exposed  to  smallpox  infection 
and  introduce  in  this  way  a  drop  of  the  smallpox  virus. 
Patients  thus  inoculated  developed  a  mild  form  of  the 
disease,  from  which  they  usually  recovered,  and  which 
apparently  protected  them  from  another  attack.  The 
custom  attracted  the  interest  of  Lady  Mary  Wortley- 
Montague,  the  wife  of  the  British  Ambassador  to  Con- 
stantinople, and,  through  her,  the  attention  of  the  scientific 
men  of  the  day  (about  1718).  The  method  had  the  draw- 
back, however,  that  the  disease,  though  mild,  was  con- 
tagious. 

Toward  the  end  of  the  eighteenth  century  another 
English  woman  observed  that  during  an  epidemic  of  small- 
pox none  of  her  dairy-maids  fell  sick.  She  found  that  they 
attributed  their  protection  to  the  fact  that  they  had  all 


424      ELEMENTARY   BACTERIOLOGY   AND   IMMUNITY 

had  cowpox  (or  vaccinia),  which  they  had  acquired  from 
the  cows  they  tended  through  abrasions  on  the  hands  or 
arms.  Inquiry  showed  that  the  belief  that  vaccinia  pro- 
tected from  smallpox  was  general  among  the  farming 
classes. 

Edward  Jenner,  a  noted  London  physician,  conceived 
the  idea  of  inoculating  with  the  virus  of  cowpox  instead 
of  smallpox,  thus  producing  the  same  immunity  with  a 
disease  which  had  the  advantage  of  being  mild  and  non- 
contagious.  To  this  form  of  inoculation  he  gave  the  name 
vaccination. 

Jenner  first  practised  vaccination  in  1796.  So  great  a 
success  attended  the  practice  that  it  rapidly  became  the 
customary  means  of  protection  against  smallpox.  Later, 
with  the  idea  of  stamping  out  effectually  so  dreaded  and 
wide-spread  a  disease,  it  became  law  in  many  parts  of  the 
world  that  all  infants  should  be  vaccinated.  Only  in  late 
years  have  the  laws  been  relaxed. 

The  immunity  to  smallpox  conferred  by  vaccination  is 
not  considered  to  last  more  than  a  few  years,  nor  is  the 
immunity  always  absolute.  If  the  disease  is  contracted, 
however,  after  recent  vaccination,  it  is  in  a  mild  form. 

Technic. — The  process  of  vaccination  consists  in  super- 
ficially scarifying  the  skin  with  a  sterile  needle  or  fine 
knife,  and  rubbing  over  the  surface  a  drop  of  lymph  from 
a  calf  previously  inoculated  with  vaccine.  Cowpox 
vaccination  produces  few  physical  symptoms,  its  chief 
manifestation  being  a  characteristic  cowpox  pustule  at 
the  seat  of  vaccination. 

Inoculation. — The  system  of  inoculation  originated  by 
Louis  Pasteur,  by  which  work  he  is  most  widely  known, 
consists  in  injecting  what  he  calls  an  "  attenuated  virus," 
that  is,  a  poison  highly  diluted,  into  the  blood,  with  the 
effect  that  an  extremely  mild  form  of  the  disease  is  de- 
veloped, which  yet  is  sufficient  to  confer  immunity. 
The  Pasteur  school  employs  many  different  methods 
of  obtaining  this  attenuation,  some  of  them  very  com- 
plicated. Pasteur's  method  of  inoculation  is  universally 
used  as  a  preventive  of  hydrophobia  in  persons  who  have 
been  bitten  by  rabid  animals.  It  is  also  used  in  some  othef 


IMMUNITY  425 

diseases  of  animals,  but  not  at  the  present  date  in  any 
other  infectious  disease  of  man. 

Tuberculin.— In  1892  Koch  introduced  inoculation  in 
the  treatment  of  tuberculosis,  using  a  dilute  culture  of  the 
tuberculosis  bacillus,  to  which  he  gave  the  name  tuber- 
culin. On  persons  that  are  free  from  tuberculosis  no 
effect  is  produced;  on  others  both  a  local  reaction  and  pro- 
nounced physical  symptoms  develop.  At  first  immense 
hopes  were  raised  that  a  cure  for  tuberculosis  had  been  dis- 
covered. Its  use,  however,  was  soon  found  to  be  attended 
with  danger  to  the  patient,  and  it  was  abandoned  as  a 
method  of  treatment.  It  is  at  present  used  on  cattle  and 
pigs  for  purposes  of  diagnosis,  in  those  parts  of  the  world 
where  the  law  requires  that  animals  to  be  used  as  food 
should  be  destroyed  if  proved  tuberculous. 

Antitoxins. — In  producing  active  immunity  the  whole 
process  is  developed  in  the  system  of  the  patient;  in  pro- 
ducing passive  immunity,  half  the  process  is  developed  in 
one  of  the  lower  animals.  The  immunizing  agent  is  con- 
tained in  the  serum  of  an  animal,  usually  the  horse,  which 
has  been  injected  with  repeated  increasing  doses  of  a  bac- 
terial toxin  until  an  extremely  high  degree  of  resistance 
has  been  developed.  The  serum  is  injected  under  the  skin 
of  a  patient  suffering  from  the  disease,  and  after  a  varying 
number  of  doses  produces  a  temporary  immunity  in  the 
patient.  Such  a  serum  is  spoken  of  as  an  antitoxin.  An- 
titoxins are  thus  produced  from  the  toxins  of  diphtheria, 
tetanus,  streptococcus  infections,  pneumonia,  and  a  few 
other  infections.  At  the  present  day  the  use  of  diphtheria 
antitoxin  is  universal,  and  has  enormously  reduced  the 
death-rate  of  this  malady.  Tetanus  antitoxin  is  con- 
sidered efficacious  as  a  prophylactic  if  injected  at  the  time 
of  an  injury  or  soon  after,  but  is  not  considered  of  much  use 
once  the  disease  has  manifested  itself.  The  use  of  anti- 
streptococcus  serum  is  gaining  in  favor  in  many  parts  in 
the  treatment  of  general  sepsis.  Other  serums  are  pre- 
pared, with  bactericidal  properties,  for  use  in  the  treat- 
ment of  typhoid  fever,  dysentery,  tuberculosis,  cerebro- 
spinal  meningitis,  and  other  infections;  the  efficacy  is, 
however,  still  more  or  less  in  the  experimental  stage. 


426      ELEMENTARY   BACTERIOLOGY   AND   IMMUNITY 

Technic. — In  producing  an  antitoxin  the  procedure 
practised  at  the  present  day  is  as  follows:  The  bacillus 
of  diphtheria,  for  example,  is  cultivated  in  a  bouillon  and 
developed  in  an  incubator.  In  growing,  the  bacillus  ex- 
cretes its  toxin,  which  permeates  the  culture-media.  When 
sufficient  toxin  is  formed,  the  culture  is  filtered  to  get  rid 
of  the  living  bacteria,  and  a  small  dose  is  injected  into  a 
horse,  with  the  result  that  a  mild  attack  of  diphtheria  is 
developed.  From  time  to  time  fresh  injections  of  the  toxin 
are  administered,  until  the  horse  is  able  to  receive  enor- 
mous doses  of  the  toxin  without  developing  symptoms  of 
the  disease.  The  horse  is  then  bled,  and  the  serum,  which 
contains  the  immunizing  agent,  is  collected  and  put  up  in 
hermetically  sealed  tubes,  after  the  strength  of  the  serum 
has  been  tested  on  guinea-pigs,  rats,  or  similar  animals. 

Measurement. — The  antitoxin  serum  is  measured  by  its 
potency  and  not  by  its  bulk.  The  standard  of  measure- 
ment has  been  named  the  immunity  unit  by  Behring,  the 
scientist  who  first  introduced  the  methods  of  developing 
and  using  antitoxins.  The  unit  represents  an  antitoxic 
principle  sufficient  to  enable  a  guinea-pig  weighing  250 
grams  to  resist  an  injection  of  the  toxin  100  times  stronger 
than  a  normally  fatal  dose  for  four  days  (Williams). 

Persons  exposed  to  diphtheric  infection  usually  receive 
an  injection  of  500  units;  patients  with  diphtheria,  1000 
to  2000  units  at  a  time,  repeated  at  intervals  until  the 
physical  symptoms  show  a  decided  improvement. 

Passive  immunity  is  developed  much  more  rapidly  than 
active  immunity;  in  many  cases  the  effects  of  a  dose  of 
antitoxin  are  perceptible  in  a  few  hours  after  the  first 
injection.  The  immunity  thus  conferred  is,  however, 
transitory;  whereas,  as  we  have  seen,  in  many  instances 
active  immunity  may  last  through  life. 

Without  the  phenomenon  of  immunity,  either  natural  or 
acquired,  the  human  body  would  be  a  constant  prey  to 
infectious  diseases;  bacteria  once  invading  a  body  would 
continue  to  develop  and  produce  their  toxins  until  the 
death  of  the  victim  took  place. 

Theories  of  Immunity. — Many  theories  are  advanced 
to  explain  the  phenomenon  of  immunity,  no  one  of  which 


IMMUNITY  427 

is  yet  considered  conclusive.  Pasteur  held  that  during 
an  attack  of  an  infectious  disease  the  bacteria  fed  on  cer- 
tain organic  elements  in  the  body  until  the  supply  was  ex- 
hausted, following  which  the  bacteria  were  starved  out; 
immunity  then  lasted  until  this  necessary  food  was  renewed 
in  the  body,  in  many  instances  for  the  rest  of  the  life. 
This  hypothesis  is  known  as  the  exhaustion  theory.  Others 
hold  that  bacteria,  by  their  own  excretions,  produce  a 
medium  in  which  they  cannot  develop.  Others  again 
attribute  immunity  to  chemical  changes  in  the  blood,  the 
result  of  bacterial  activity,  which  give  to  the  blood  certain 
bactericidal  powers,  such  as  the  development  of  bodies 
known  as  alexins,  which,  by  a  complicated  process,  have 
the  power  of  dissolving  bacteria  (bacteriolysis). 

Other  substances  produced  in  the  blood  during  certain 
infections  are  called  agglutinins;  they  cause  clumping  or 
agglutination  of  certain  bacteria,  with  a  loss  of  motility 
where  the  bacteria  have  this  property.  We  have  seen  that 
the  blood  of  typhoid-fever  patients  has  this  property. 
(See  Widal  Reaction.)  It  is  not  yet  determined  whether 
the  agglutiryns  play  an  active  part  in  the  production  of 
immunity. 

Without  directly  bearing  on  her  work,  it  is  worth  while 
for  the  student  nurse  to  understand  those  theories  on  this 
subject  most  generally  referred  to,  and  to  which  she  will 
frequently  find  allusion  in  the  text-books  she  may  consult. 

1.  The  Theory  of  the  Feeding  Cell. — Experiments  show 
that  certain  of  the  leukocytes,  or  white  corpuscles,  have 
the  property  of  fastening  on  certain  substances  in  the  blood 
and  ingesting  them.  From  this  property  they  are  called 
phagocytes,  or  feeding  cells.  The  phagocytes  are  the 
scavengers  of  the  body.  If  a  part  of  the  body  receives  an 
injury,  we  know  that  at  once  there  is  a  migration  of 
leukocytes  to  the  point  of  lesion;  these,  fastening  on  the 
inflammatory  processes,  ingest  them,  sometimes  destroy- 
ing them,  sometimes  conveying  them  to  remote  parts  of 
the  system.  Where  their  efforts  are  successful,  we  say 
that  the  inflammatory  processes  have  become  absorbed, 
or  that  resolution  has  taken  place. 

Metchnikoff,  a  modern  scientist,  proposed  (about  1890), 


428      ELEMENTARY   BACTERIOLOGY   AND    IMMUNITY 

as  a  theory  to  explain  the  action  on  the  body  in  encounter- 
ing bacteria,  a  similar  attraction  of  the  part  of  the  leuko- 
cytes for  bacteria  invading  the  system.  We  may  imagine 
the  invading  bacteria  being  met  by  a  host  formed  of 
leukocytes.  If  the  leukocytes  win  in  the  struggle,  the 
bacteria  are  destroyed;  but  if  the  leukocytes  fail  to  de- 
fend the  body,  the  bacteria  are  victorious,  and  the  body 
succumbs  to  the  disease.  The  theory,  however,  falls 
short  in  many  circumstances.  For  example,  it  does  not 
explain  immunity  from  infections  produced  by  toxins 
excreted  by  the  bacteria. 

2.  Ehrlich's  Theory. — A  second  theory  of  immunity  ad- 
vanced by  Ehrlich  to  explain  the  resistance  of  the  body-cell 
to  toxins  is  more  difficult  to  follow.  It  pictures  hypo- 
thetically  each  body-cell  as  being  surrounded  by  a  number 
of  molecules  which  he  calls  side-chains.  The  function  of 
these  bodies  is  to  attract  the  necessary  food-substances 
for  the  cell.  Each  molecule  of  a  side-chain  is  called,  from 
this  fact,  the  receptor.  The  receptor  has  a  peculiar  shape 
into  which  it  is  necessary  for  the  food  atom  to  fit  exactly, 
as  one  piece  of  wood  may  be  dove-tailed  into  another  or 
a  ball  may  fit  exactly  a  socket.  A  food-atom  fitting  ex- 
actly into  the  receptor  is  then  passed  into  the  cell,  where 
it  is  devoured  by  the  many  atoms  which  comprise,  accord- 
ing to  this  theory,  the  body-cell. 

Ehrlich  now  imagines  the  invading  bacteria  to  produce 
substances  (toxins)  of  the  same  form  as  the  food  mole- 
cules, and,  therefore,  also  fitting  the  receptors.  These 
bodies  are  pictured  in  two  parts.  The  first,  to  which  he 
gives  the  name  haptophore,  is  the  body  that  must  exactly 
fit  the  receptor.  To  the  haptophore  is  attached  a  poison- 
ous substance,  the  toxophore,  which  is  thus  introduced 
into  the  receptor  by  the  haptophore,  and  through  the 
receptor  invades  the  cell  which  it  attempts  to  destroy.  A 
conflict  now  takes  place  between  the  toxophores  and  the 
cell  atoms.  If  the  former  prevails,  the  cell  is  destroyed. 
In  many  instances,  however,  the  presence  of  the  toxophore 
excites  the  cell  to  abnormal  activity,  with  the  result  that 
many  additional  side-chains  are  developed — more  than  are 
necessary  to  the  individual  cell.  The  superfluous  receptor 


IMMUNITY  429 

is  thrown  into  the  blood-stream  and  there  meets  the  toxin 
molecule  (haptophore  and  toxophore),  which  it  engages, 
thus  preventing  the  harmful  molecule  from  reaching  the 
cell.  Should  a  sufficient  number  of  receptors  be  present 
in  the  blood-stream  to  engage  the  large  majority  of  toxin 
molecules,  the  effect  is  to  neutralize  their  activity  and 
immunity  results. 

This  theory  demonstrates  immunity  by  the  develop- 
ment of  a  neutralizing  body  or  antitoxin,  which  has  an 
affinity  for  the  molecules  of  a  soluble  toxin  developed  in 
the  body  as  a  result  of  bacterial  activity.  It  is  a  condi- 
tion of  acquired  immunity.  It  may  also  serve  as  an  illus- 
tration of  natural  immunity.  As  it  is  necessary  for  the 
haptophore  exactly  to  fit  into  the  receptor,  should  the  cell 
possess  no  receptor  into  which  the  haptophore  will  fit, 
the  cell  will  be  safe  from  the  invasion  of  that  particular 
toxin  molecule. 

3.  The  Opsonic  Theory. — In  quite  recent  years  much 
attention  has  been  attracted  to  what  is  known  as  the 
opsonic  theory  of  immunity,  advanced  by  Sir  A.  E. 
Wright,  of  London. 

Wright  teaches  that  in  the  blood-serum  are  certain 
substances  which  he  calls  opsonins,  from  the  Latin  word 
opsono,  I  prepare  for  dinner.  This  substance  apparently 
acts  on  the  bacteria  in  such  a  way  as  to  prepare  them  as 
food  for  the  leukocytes,  or,  on  the  other  hand,  it  may  act 
on  the  leukocytes  so  as  to  stimulate  their  appetite  for  the 
bacteria.  Experiments  show  that  there  is  no  attraction 
between  the  leukocyte  and  the  bacterial  cell  except 
through  the  medium  of  the  blood-serum.  The  resistance 
of  the  body,  according  to  Wright's  opsonic  theory,  de- 
pends on  the  presence  of  the  opsonins.  The  amount 
of  "  opsonins  "  present  at  different  times  varies  greatly, 
causing  a  corresponding  variation  of  the  amount  of  re- 
sistance shown  by  the  body  to  the  invasion  of  bacteria. 
Wright  teaches  that  this  substance  is  either  produced  or 
increased  by  the  presence  of  dead  bacteria.  In  the 
ordinary  course  of  an  infectious  illness  a  large  number  of 
bacteria  die,  and  by  this  theory  become  themselves  the 
source  of  this  immunizing  power. 


430      ELEMENTARY   BACTERIOLOGY   AND    IMMUNITY 

In  carrying  this  hypothesis  into  practice,  bacteria  that 
have  been  devitalized  by  heat  are  injected  into  the  cir- 
culation of  the  patient,  with  the  result  of  increasing  the 
"  opsonins  "  and  hastening  the  period  of  immunity  or 
establishing  a  cure.  Each  bacteria  apparently  produces 
only  its  own  variety  of  "  opsonins."  For  example,  an 
injection  of  dead  tubercle  bacilli  does  not  increase  the 
resistance  of  the  body  to  any  bacteria  except  the  tubercle 
bacillus. 

This  teaching  of  Sir  A.  E.  Wright  has  opened  up  a 
new  method  of  treatment  for  many  infectious  diseases  by 
repeated  injections  of  devitalized  preparations  of  the 
germ  which  causes  the  specific  disease.  The  practice  has 
met  with  its  greatest  success  in  the  treatment  of  infec- 
tious diseases  of  the  skin. 

In  connection  with  this  treatment  the  term  opsonic 
index  is  met  with.  The  index  of  an  individual  rep- 
resents the  degree  of  opsonic  potency  his  blood-serum 
evinces  toward  a  particular  germ.  This  is  ascertained  by 
taking  a  counted  number  of  leukocytes  which  have  been 
isolated  from  the  patient's  blood  and  mixing  them,  in 
some  of  his  own  serum,  with  a  known  number  of  devital- 
ized germs  of  the  infection  under  consideration.  After 
a  period  the  bacteria  are  again  counted.  Say,  for  ex- 
ample, that  in  a  given  case  it  is  ascertained  that  each 
leukocyte  will  account  for  six  bacteria — the  patient's 
index  is  said  to  be  1  in  6. 

Under  treatment,  i.  e.,  by  injection  of  devitalized  bac- 
teria, the  opsonic  potency  may  be  greatly  increased, 
each  leukocyte  accounting  for  a  larger  number  of  bac- 
teria; the  index  is  then  said  to  be  raised.  Conditions 
which  lessen  the  normal  resistance  of  the  body  as  de- 
scribed above  cause  the  opsonic  index  to  be  lowered. 
Repeated  examinations  of  the  blood  are  necessary  to  keep 
watch  on  the  opsonic  index,  and  the  injections  are  given 
according  to  the  indications  of  the  index. 

The  above  are  only  epitomes  of  theories  of  immunity 
on  which  an  immense  amount  has  been  written  in  later 
years.  They  will  serve,  however,  to  present  a  picture 
to  the  imagination  of  ways  by  which,  in  the  first  place, 


ACTION    OF   PATHOGENIC    BACTERIA  431 

the  bacteria  themselves,  and,  in  the  second  place,  the 
toxins  they  produce,  may  be  met  and  overcome  in  the 
body  tissues.  We  must  remember  that  these  theories 
are  all  links  in  a  chain  of  evidence  that  is  slowly  being 
accumulated  by  patient  research  and  logical  deduction. 
A  discovery  of  to-morrow  may  alter  the  whole  teaching 
of  to-day,  or,  on  the  other  hand,  may  establish  what  has 
been  regarded  as  a  doubtful  hypothesis  as  a  principle 
of  the  first  importance. 

ACTION  OF  PATHOGENIC  BACTERIA 

To  return  once  more  to  the  consideration  of  the  action 
of  the  pathogenic  bacteria  on  the  tissues: 

Incubation  Period. — Between  the  actual  time  that  the 
germ  of  a  specific  disease  gains  entrance  to  the  body  and 
the  development  of  the  first  symptoms  of  the  disease  is  a 
period  of  apparent  quiescence  known  as  the  period  of 
incubation.  This  period  varies  in  the  different  diseases 
and  to  some  extent  also  in  the  same  disease  in  different 
patients,  depending  probably  on  the  resistance  of  the 
individual.  During  this  time  the  toxin  is  being  developed. 
As  the  toxins  begin  to  be  absorbed  by  the  tissues  the 
preliminary  symptoms  or  prodromes  make  their  appear- 
ance. 

The  average  time  of  incubation  in  the  infectious  fevers 
is  as  follows: 

Diphtheria Two  to  seven  days. 

Scarlet  fever A  few  hours  to  seven  days. 

Smallpox Ten  days  to  two  weeks. 

Chicken-pox Fourteen  to  sixteen  days. 

Measles Ten  days  to  two  weeks. 

German  measles One  to  three  weeks. 

Typhoid  fever Two  to  three  weeks. 

Typhus  fever A  few  hours  to  two  weeks. 

Mumps Two  to  three  weeks. 

Erysipelas Three  to  seven  days. 

Tetanus A  few  days  to  three  weeks. 

Cholera Two  to  five  days. 

Yellow  fever Two  to  three  weeks. 

— From  A.  A.  Stevens. 

Surgical  infection  due  to  a  variety  of  the  staphylo- 
coccus  or  streptococcus  bacteria  requires  about  three 


432      ELEMENTARY   BACTERIOLOGY   AND   IMMUNITY 

days  for  incubation.  The  methods  of  combating  surgical 
infection  are  discussed  in  the  following  chapter. 

Period  of  Invasion. — Immediately  following  the  period 
of  incubation  is  the  period  of  invasion,  corresponding  to 
the  elaboration  of  the  toxins  and  the  beginning  of  their 
absorption  by  the  tissues.  During  this  period  the  tem- 
perature rises  until  it  reaches  its  height.  It  is  accom- 
panied by  physical  manifestations,  such  as  malaise, 
languor,  gastric  disturbances,  chilliness,  or  rigors,  and 
in  some  cases  by  characteristic  premonitory  symptoms  of 
the  special  disease,  which  are  known  as  prodromes.  Such, 
for  example,  are  the  coryza  of  measles,  the  sore  throat  of 
diphtheria  and  scarlet  fever,  and  others. 

Fastigium. — The  significance  of  the  fastigium  and  the 
decline  of  a  fever  have  already  been  briefly  pointed  out. 
(See  also  p.  199.)  The  fastigium  is  the  period  of  toxemia 
during  which  the  body-cells  are  poisoned  by  the  toxin 
elaborated  by  the  activity  of  the  bacteria.  Besides 
the  characteristic  symptoms  of  the  special  disease,  the 
condition  is  accompanied  by  general  symptoms  common 
to  the  acute  infectious  disorders,  of  which  the  most  im- 
portant are  fever,  prostration,  emaciation  from  inter- 
ference with  the  processes  of  nutrition,  digestive  disorders, 
especially  constipation  or  diarrhea,  and  nervous  symptoms, 
such  as  wakefulness,  delirium,  stupor,  or  unconsciousness. 

The  decline  is  coincident  with  the  elaboration  in  the 
body,  probably  we  have  seen  in  the  blood,  of  substances 
with  antitoxic  properties,  and  ushers  in  a  period  of  im- 
munity of  greater  or  less  duration. 

At  the  present  day,  except  in  one  instance,  no  remedy  is 
in  general  use  which  will  actually  cut  short  an  infectious 
fever.  The  treatment  of  such  cases  is  entirely  directed  to 
the  amelioration  of  the  symptoms  and  the  support  of  the 
bodily  strength  by  confinement  to  bed,  quiet,  and  judi- 
cious diet.  The  exception  is  the  use  of  antitoxin  serum 
in  diphtheria,  the  remedial  effects  of  which  are  frequently 
demonstrated  in  a  few  hours  after  the  injection  of  the 
serum. 

Drugs  with  Specific  Action. — In  the  department  of 
materia  medica  a  few  drugs  are  recognized  as  having  a 


NURSING   IN   INFECTIOUS  DISEASES  433 

specific  effect  on  certain  infectious  disorders.  Such  are 
quinin,  largely  used  as  a  prophylactic  in  malaria;  salicylic 
acid,  which  relieves  the  pain  and  reduces  the  fever  in 
acute  rheumatoid  affections;  and  mercury  and  iodid  of 
potassium,  both  largely  used  in  the  treatment  of  syphilis. 
As  has  already  been  stated,  the  scientists  of  the  pres- 
ent day  are  devoting  much  of  their  time  and  energies 
to  the  discovery  of  immunizing  agents  for  the  various 
infectious  disorders,  which  shall  prove  as  effectual  as  the 
diphtheria  antitoxin  has  been  shown  to  be.  Their  work 
is,  however,  still  largely  in  the  experimental  stage. 

NURSING  IN  INFECTIOUS  DISEASES 

In  nursing  an  infectious  fever  the  sources  of  contagion 
must  be  recognized  and  protective  measures  taken  ac- 
cordingly. It  must  be  remembered  again  that  the  germs 
of  a  disease  are  usually  found  in  greatest  numbers  in  the 
lesions  characteristic  of  the  disease.  Any  abnormal 
discharge,  therefore,  the  result  of  the  disease,  will  probably 
contain  the  germs  of  the  infection,  and  must  invariably 
be  disinfected. 

In  the  water-borne  diseases,  typhoid  fever,  cholera, 
dysentery,  and  summer  diarrhea,  the  special  lesions 
being  in  the  alimentary  tract,  the  stools  are  the  chief 
source  of  infection,  and  must  be  rigorously  disinfected 
until  convalescence  is  established. 

In  typhoid  fever  the  usual  rule  is  to  consider  conva- 
lescence established  ten  days  after  the  temperature  has 
become  normal.  Until  this  time  the  bed-linen  must  also 
be  disinfected,  and  the  dishes  and  utensils  used  for  the 
patient  should  be  marked  and  set  aside  for  his  use  only. 
The  diapers  of  a  baby  with  summer  diarrhea  should  be 
placed  in  a  disinfectant  immediately  they  are  removed. 

In  typhoid  fever  the  bacteria  are  frequently  present  in 
the  urine,  which  should,  therefore,  also  be  disinfected. 
(See  Disinfectants.)  The  germs  may  also  be  found  in 
any  discharge  from  a  suppurative  condition,  in  the 
vomitus,  and  in  the  sordes  which  collect  about  the 
teeth  and  lips  of  patients  where  the  mouth  has  been 
neglected.  In  this  latter  condition  the  germs  may  also  be 

28 


434      ELEMENTARY  BACTERIOLOGY  AND   IMMUNITY 

in  the  breath.  To  those  attending  these  cases  the  chief 
source  of  danger  lies  in  getting  the  hands  infected  while 
attending  to  the  patient,  changing  the  bed-linen,  or 
cleaning  the  mouth.  It  should  be  a  rule  with  no  excep- 
tions that  the  hands  must  be  washed  and  disinfected 
after  every  such  act,  and  again  invariably  before  going 
to  a  meal. 

In  disposing  of  the  stools,  they  should  be  disinfected 
(p.  468)  before  being  thrown  down  the  soil-pipe.  In 
country  places,  where  there  is  no  water  drainage,  a  hole 
should  be  dug  and  the  stools  placed  therein  and  covered 
with  lime.  Great  care  must  be  exercised  to  choose  a 
site  away  from  all  water-supply,  and  especially  from 
natural  wells.  When  the  case  is  over,  the  bed  and  bed- 
ding should  be  disinfected. 

With  the  above  precautions  and  scrupulous  cleanliness, 
typhoid  fever  cases  and  cases  of  dysentery  or  diarrhea 
should  not  be  a  menace  to  the  health  of  the  other  in- 
habitants of  a  house.  Where  possible,  they  should  be 
nursed  in  a  room  by  themselves,  but  the  room  need  not 
be  isolated,  in  the  strict  sense  of  the  word.  Cholera  ap- 
pears to  be  more  actively  contagious,  and  cases  should  be 
isolated. 

Diphtheria. — The  germs  in  a  case  of  diphtheria  are 
present  in  the  discharges  of  the  nose  and  throat,  conse- 
quently in  the  breath,  and  especially  in  the  characteristic 
membrane.  All  such  discharges,  the  sputum,  the  pieces 
of  membrane,  and  vomitus  must  be  disinfected.  Sputum, 
etc.,  should  be  received  on  pieces  of  rag  or  paper  and  burned 
at  once,  if  possible.  If  not,  they  should  be  thrown  in  a 
covered  vessel  containing  a  disinfectant  until  destroyed. 

The  air  immediately  round  the  patient  may  contain 
germs,  but  the  infection  is  not  carried  by  fomites,  unless 
actually  soiled  with  the  discharges.  Since  the  breath  is 
infected,  kissing  or  nursing  child  patients  in  the  arms 
is  forbidden,  and  the  nurse  must  be  careful  to  avoid 
letting  the  patient  cough  in  her  face.  The  patient  should 
be  isolated,  and  all  vessels  and  dishes  kept  for  his  exclusive 
use.  The  linen  must  be  disinfected  before  being  sent  to 
the  laundry,  and  should  be  washed  separately.  The 


NURSING   IN   INFECTIOUS   DISEASES  435 

patient  is  actively  infectious  as  long  as  there  is  any  cough 
or  discharge  from  the  throat  or  nose.  He  is  not  recog- 
nized as  free  from  contagion  until  no  culture  of  the 
Klebs-Loffler  bacillus  can  be  obtained  from  the  throat. 

Disinfection  should  include  fumigation  of  the  room  and 
disinfection  of  the  bed,  bedding,  furniture,  etc.,  followed 
by  thorough  cleaning.  In  a  private  house  the  walls 
should  be  repapered. 

Scarlet  fever  is  one  of  the  most  actively  contagious  of 
diseases.  The  germs  are  present  in  discharges  from  the 
nose  and  throat,  or  any  other  suppurative  condition,  such 
as  otitis  media,  and  in  the  particles  of  epithelium  shed 
after  the  rash  has  faded.  Desquamation  lasts  from  four 
to  eight  weeks.  As  long  as  there  is  the  smallest  particle 
of  desquamation  or  any  discharge  from  throat,  nose,  or 
local  abscess,  the  patient  is  in  an  infective  condition,  and 
must  not  mix  with  others.  In  these  cases  strict  isolation  is 
imperative.  The  room  chosen  should  be  as  far  removed  as 
possible  from  the  rest  of  the  house.  The  doors  should  be 
kept  closed,  and  a  curtain,  kept  continually  wet  with  a 
disinfectant,  should  be  hung  in  front  of  the  entrance  com- 
municating with  the  rest  of  the  house. 

The  same  precautions  should  be  taken  as  in  diphtheria. 
In  addition,  the  separated  particles  of  epithelium  must 
be  destroyed.  Many  doctors  keep  the  skin  lubricated 
with  an  antiseptic  ointment  or  oil,  and,  in  addition,  after 
the  fever  has  disappeared,  daily  hot  baths  are  given  to 
encourage  desquamation. 

The  sweepings  of  the  room  will  probably  contain  the 
germs  of  the  infection,  and  should,  where  practical,  be 
burned  at  once.  Even  in  the  summer  they  may  be 
wrapped  in  a  newspaper  and  burned  on  the  hearth  or  in 
an  empty  garbage-pail.  Dusters  and  sweeping  brooms 
should  be  disinfected  and  washed  daily  after  use. 

Scarlet  fever  infection  is  also  conveyed  by  fomites. 
Every  unnecessary  article  in  the  sick-room  is,  therefore, 
a  future  menace.  Letters,  books,  work,  toys,  actually 
handled  by  the  patient  cannot,  as  has  been  said,  be  dis- 
infected with  any  certainty.  What  are  not  destroyed 
are  generally  welcomed  in  a  fever  hospital. 


436      ELEMENTARY   BACTERIOLOGY   AND   IMMUNITY 

Nurses  taking  care  of  such  cases  should  not  go  to  the 
other  rooms  of  the  house,  and  should  not  mix  with  others 
unless  out-of-doors,  after  their  clothes  have  been  changed 
and  they  have  taken  a  bath.  Clean  linen  wrappers 
should  be  provided  to  cover  entirely  the  clothing  of 
doctors  or  parents  that  may  visit  the  sick-room. 

When  convalescence  is  complete,  the  patient  receives 
a  thorough  disinfecting  bath  and  is  dressed  in  clothes 
that  have  not  been  near  the  sick-room.  The  room  and 
all  the  contents  are  fumigated  and  cleaned.  Repainting 
and  papering  should  be  done  where  possible.  Whitewash 
is  in  itself  a  disinfectant,  and  is  generally  practical  in  the 
homes  of  the  poor. 

Smallpox  is  the  most  readily  communicable  of  all  dis- 
eases. Infection  is  conveyed  in  the  breath  of  the  patient, 
the  discharges  of  the  nose,  mouth,  and  conjunctiva,  in 
the  vomitus,  sputum,  probably  in  the  excretions,  and  in 
the  desquamating  skin. 

The  care  to  be  taken  is  the  same  as  in  scarlet  fever. 
The  fomites  are  peculiarly  tenacious  of  the  infection,  and 
everything  practical  used  by  the  patient  should  be  des- 
troyed except  articles  that  can  be  boiled  or  disinfected 
with  certainty.  Old  linen  and  old  bedding,  if  available, 
should  be  used  and  destroyed  when  finished  with.  The 
room  should  contain  the  least  possible  amount  of  furniture 
and  absolutely  no  rugs,  hangings,  or  decorations.  After 
fumigation,  walls,  ceilings,  and  floors  must  receive  special 
cleaning.  Repapering  or  white  washing  is  imperative. 
In  epidemics  temporary  huts  or  canvas  tents  are  preferred 
to  more  permanent  buildings. 

Protection  for  the  attendants  lies  in  vaccination.  No 
nurse  should  be  permitted  to  go  on  duty  on  a  smallpox 
case1  unless  vaccinated  successfully  within  two  years,  and 
all  likely  to  come  in  direct  or  indirect  contact  with  the 
case  should  be  vaccinated. 

As  in  scarlet  fever,  infection  lasts  as  long  as  there  is  any 
discharge  from  the  surface  or  cavities  and  until  desquama- 
tion  is  entirely  finished. 

Measles. — The  infection  of  measles  is  also  contained 
in  the  discharges  of  the  nose  and  throat  and  in  the  des- 


NURSING   IN   INFECTIOUS   DISEASES  437 

quamating  skin.  Measles  appears  to  spread  more  quickly 
through  a  community  or  a  hospital  ward  than  any  other 
infection.  The  reason  is  probably  the  droplet  infection 
from  the  accompanying  coryza.  For  this  reason,  if 
measles  is  suspected,  the  patient  should  be  isolated 
on  the  earliest  appearance  of  the  coryza.  The  same 
may  be  said  of  whooping-cough.  Cases  of  measles  should 
be  isolated  until  desquamation  is  over.  In  all  respects 
the  precautions  are  the  same  as  those  used  in  scarlet 
fever.  As  desquamation  is  much  less  severe  than  in 
scarlet  fever,  the  fomites  are  more  readily  disinfected. 

Chicken-pox,  German  measles,  mumps,  and  whooping- 
cough,  all  air-borne  infections,  should  also  be  isolated  and 
precautions  taken  along  the  lines  indicated. 

Tuberculosis. — The  tubercle  bacillus  attacks  practically 
all  organs  and  structures  of  the  body.  The  lesions  are 
frequently  complicated  by  suppuration,  and  in  these  cases 
the  discharges  contain  the  bacillus  and  must  be  disin- 
fected or  destroyed.  Pulmonary  tuberculosis  is  the  most 
generally  infectious  variety  of  this  disease.  The  infection 
is  contained  in  the  sputum,  and  communicated  to  the  air 
by  droplet  infection,  or  directly  from  the  breath  of  the 
patient  in  kissing  or  in  sleeping  in  the  same  bed. 

In  nursing  a  case  of  pulmonary  tuberculosis  isolation 
should  always  be  attempted  and  enforced  where  possible. 
The  minimum  care  should  insist  on  separate  sleeping 
room  and  separate  linen,  dishes,  and  utensils  for  the 
patient's  use.  The  sputum  should  be  received  in  special 
cups  or  flasks  which  can  either,  according  to  their  make,  be 
burned  or  disinfected  by  boiling  at  least  once  a  day. 
Patients  must  be  taught  to  spit  only  into  the  cups  and  to 
keep  clothing,  hands,  etc.,  free  from  contamination. 
Handkerchiefs,  if  these  must  be  used,  should  be  disin- 
fected before  being  sent  to  wash,  and  boiled  in  the  process. 
The  bed  and  personal  linen  should  also  be  disinfected.  In 
poor  homes  rags  and  pieces  of  soft  paper  should  be  given 
to  the  patient  and  he  should  be  taught,  after  using  them, 
to  put  them  in  a  thick  paper  bag  in  which  they  can  sub- 
sequently be  burned.  Nurses  should  remember  that, 
whatever  compromises  they  may  be  obliged  to  make, 


438      ELEMENTARY   BACTERIOLOGY   AND   IMMUNITY 

scientists  consider  that  isolation  of  the  case  from  healthy 
people  is  imperative  if  this  disease  is  ever  to  be  stamped 
out. 

Erysipelas. — The  infection  of  erysipelas  is  contained 
in  the  desquamating  particles  of  skin  and  in  discharges 
from  the  affected  area.  It  is  readily  carried  in  the  cloth- 
ing of  the  attendants,  and  in  instruments,  dressings,  etc., 
used  for  such  cases.  At  the  same  time,  as  an  abrasion  of 
the  skin  is  necessary  for  the  entrance  of  the  special  germ, 
cases  of  erysipelas  may  be  nursed  with  impunity  in  medical 
wards.  Care  should  be  taken  to  prevent  any  contact, 
however  remote,  with  surgical  cases.  Nurses  caring  for 
erysipelas  patients  should  not  be  allowed  in  the  surgical 
wards  or  in  the  operating-room,  and  should  not  mix  with 
others  from  these  departments  until  the  clothes  have  been 
changed.  Dressings  from  erysipelas  cases  should  be  burnt 
where  practical. 

The  consideration  of  protection  from  surgical  infection 
involves  the  whole  process  of  modern  surgical  techhic,  and 
must  be  considered  in  a  chapter  by  itself. 


CHAPTER  XII 
SURGICAL  BACTERIOLOGY,  ASEPSIS 

Micro-organisms  Commonly  Met  With  in  Surgery — Infection — 
Principles  of  Antisepsis  and  Asepsis — Sterilization  by  Heat — Arnold 
Sterilizer — Autoclave — Chemical  Sterilization — Antiseptics  in  Gen- 
eral Use— Disinfection  by  Vapor — To  Disinfect  a  Room — Measur- 
ing Solutions. 

MICRO-ORGANISMS  MET  WITH  IN  SURGERY 

THE  bacteria  now  recognized  as  the  common  source  of 
surgical  infection  belong,  for  the  most  part,  to  the  micro- 
coccus  group.  Those  most  frequently  encountered  are 
of  the  staphylococcus  or  the  streptococcus  variety.  They 
are  classed  as  pyogenic,  or  pus-producing,  bacteria. 

The  following  are  the  principal  varieties: 

Staphylococcus  pyogenes  aureus  (golden  yellow},  so 
named  from  the  golden-yellow  color  produced  by  the 
organism  under  cultivation.  This  germ  is  the  common 
cause  of  what  we  know  as  local  suppuration,  and  is  found 
in  abscesses,  in  boils,  carbuncles,  and  other  suppurative 
conditions. 

Staphylococcus  pyogenes  albus  and  citreus  produce, 
under  cultivation,  a  white  and  a  lemon-yellow  color  re- 
spectively. In  other  respects  they  resemble  the  staphylo- 
coccus pyogenes  aureus,  but  they  are  less  virulent,  and 
not  so  constantly  present  as  the  cause  of  suppuration. 

One  variety  of  the  albus,  the  staphylococcus  epidermidis 
albus,  is  constantly  found  in  the  epidermis.  It  is  held 
that  no  practical  process  of  sterilization  is  sufficient  entirely 
to  remove  this  organism  from  the  skin.  Usually  innocu- 
ous, it  may  be  the  cause  of  suppuration  in  certain  condi- 
tions, especially,  it  is  said,  when  the  tissues  are  irritated 
by  the  presence  of  a  foreign  body,  such  as  stitches,  ne- 
crosed tissue,  etc. 

439 


440  SURGICAL   BACTERIOLOGY,    ASEPSIS 

Another  micro-organism  not  infrequently  associated 
with  the  staphylococcus  is  of  the  bacillus  group — the 
Bacillus  pyocyaneus  (blue  pus).  When  present  in  local 
infections,  it  gives  to  the  discharges  a  blue  or  blue-green 
color.  This  germ  is  of  a  virulent  type:  it  is  readily  car- 
ried from  one  infected  wound  to  the  other,  and,  it  is  con- 
sidered, may  also  be  the  cause  of  general  sepsis  (p.  583). 

The  Streptococcus  Pyogenes. — This  germ  is  of  a 
peculiarly  virulent  type.  It  is  the  common  cause  of  all 
forms  of  general  sepsis  (septicemia)  or  diffuse  suppuration 
(pyemia),  and  of  acute  inflammatory  conditions  of  many 
important  structures,  such  as  the  serous  membranes 
(peritonitis,  pericarditis,  etc.)  or  the  endocardium  (ulcer- 
ative  endocarditis).  A  streptococcus  closely  resembling  it, 
and  by  many  considered  identical,  is  the  cause  of  ery- 
sipelas. 

Infection  by  the  pyogenic  organisms  is  spoken  of  as 
sepsis  (or  poison).  A  condition  of  general  sepsis  is  known 
as  septicemia  (literally,  poison  in  the  blood).  Where 
septicemia  is  complicated  by  the  formation  of  secondary 
abscesses,  the  condition  is  known  as  pyemia  (literally,  pus 
in  the  blood).  Puerperal  fever  is  septicemia  caused  by 
infection  during  or  after  child-birth.  It  also  is  usually 
caused  by  the  streptococcus  pyogenes.  Streptococcous 
infection  of  the  throat  produces  a  condition  difficult  to 
differentiate  from  true  diphtheria,  except  by  microscopic 
examination  of  the  organism  developed  from  a  culture. 

WOUND  INFECTION 

Bacteria  that  cause  the  acute  contagious  fevers  are 
present  only  in  more  or  less  localized  areas,  and  are  looked 
for  chiefly  in  the  vicinity  of  persons  suffering  from  these 
maladies.  The  pus-producing  organisms,  on  the  contrary, 
are  widely  distributed,  and  are  specially  liable  to  be  found 
in  the  ordinary  dust  of  human  habitations,  which  must, 
therefore,  be  regarded  as  a  source  of  infection  for  surgical 
wounds.  Many  of  them  are  constantly  found  on  the  skin 
and  on  the  mucous  membrane  surfaces,  especially  of  the 
nose  and  mouth,  and  even  in  the  alimentary  canal. 

These  bacteria  invade  the  body  through  the  broken 


WOUND   INFECTION  441 

surface  of  the  skin  or  mucous  membrane.  They  may  be 
conveyed  by  the  dust  of  the  air,  by  water  or  lotions  used 
in  irrigating  wounds,  or  by  unclean  articles  that  come  in 
contact  with  the  wound,  such  as  dressings,  instruments,  or 
the  hands  that  touch  the  wound.  A  wound  invaded  by 
pyogenic  bacteria  is  described  as  infected. 

As  we  know,  the  bacteria  do  not  themselves  actually 
attack  the  tissues.  The  symptoms  resulting  from  their 
invasion  are  due  to  the  toxins  they  elaborate  during 
their  development. 

At  the  seat  of  lesion  the  effect  of  staphylococcic  infec- 
tion is — (1)  local  inflammation;  (2)  necrosis  of  the  in- 
flamed tissues;  (3)  liquefaction  of  the  necrosed  tissues. 
The  liquefied  tissue,  mixed  with  the  cells  of  dead  leuko- 
cytes, forms  the  thick,  inoffensive,  yellowish-green  fluid  we 
know  as  pus.  A  local,  circumscribed  collection  of  pus  is 
called  an  abscess. 

Suppuration. — The  breaking  down  of  the  tissues  into 
pus  is  known  as  suppuration. 

The  local  condition  of  suppuration  gives  rise  to  certain 
general  symptoms,  of  which  the  most  important  is  a  sharp 
rise  of  temperature,  preceded,  as  a  rule,  by  attacks  of 
shivering,  and  accompanied  by  general  malaise.  The 
physical  symptoms  are  due  to  absorption  of  the  local 
toxins.  They  subside  quickly  if  the  abscess  is  opened, 
and  further  absorption  checked  by  drainage. 

Occasionally  the  staphylococcus  gains  entrance  by  way 
of  the  hair-follicles,  the  skin  apparently  remaining  un- 
broken. A  pustule  is  produced  at  the  point  of  invasion; 
under  treatment  the  infection  may  be  checked  at  this 
point,  or  it  may  spread  to  the  surrounding  tissues,  pro- 
ducing a  boil,  or,  where  the  deeper  tissues  are  extensively 
involved,  a  carbuncle. 

Infection  by  the  streptococcus  pyogenes  is  accompanied 
by  severe  physical  symptoms.  The  principal  are:  high 
fever  of  the  intermittent  variety,  preceded  by  rigors 
(attacks  of  intense  shivering),  rapid  emaciation,  marked 
prostration,  and  persistent  diarrhea;  the  intermissions 
of  fever  are  accompanied  by  profuse  sweating.  In  many 
instances  the  condition  is  fatal.  The  term  blood-poison- 


442  SURGICAL   BACTERIOLOGY,    ASEPSIS 

ing  is  often  used  to  describe  general  streptococcus 
infection. 

The  incubation  period  for  the  pyogenic  bacteria  is 
usually  about  three  days;  it  is,  therefore,  frequently 
possible  to  trace  the  origin  of  the  infection  by  the  time  of 
the  development  of  the  symptoms. 

Mixed  Infection. — Not  infrequently  an  infected  wound 
may  be  invaded  by  a  second  organism,  both  of  which 
continue  their  activity  in  the  same  tissues.  The  condition 
is  then  described  as  mixed  infection.  The  most  common 
example  is  infection  by  the  pyogenic  organisms  in  tissues 
already  infected  by  the  tuberculosis  bacillus.  This  is 
the  process  that  produces  the  cavities  in  the  lungs  of 
phthisical  patients,  the  strumous  glands,  and  joint  abscesses 
especially  common  in  tubercular  children. 

The  tissues  of  a  healthy  human  being  present  a  consider- 
able resistance  to  the  invasion  of  the  staphylococcus  and 
streptococcus  organisms.  As  with  other  pathogenic 
bacteria,  this  resistance  is  lessened  by  conditions  that  lower 
the  health  or  vitality  of  the  individual,  and  especially  by 
alcoholism  and  by  chronic  organic  diseases,  such  as  dia- 
betes. Of  special  importance  is  it  to  remember  that  local 
resistance  is  lessened  by  local  injury  to  the  tissues,  such  as 
laceration,  bruising,  or  other  damage  from  an  accident,  or 
even  from  rough  handling  of  the  tissues  during  an  operation 
or  dressing.  Other  local  conditions  that  lessen  the  resist- 
ance are  edema,  hyperemia,  anemia,  and  the  presence  of 
dead  tissues  or  other  foreign  bodies  that  act  as  irritants. 
To  some  extent  antiseptics  also  tend  to  irritate  the  tis- 
sues, and  their  use  is  by  manv  surgeons  almost  entirely 
eliminated. 

A  wound  made  by  sharp  instruments  and  where  the 
tissues  are  carefully  handled  and  little  disturbed  offers  a 
considerable  degree  of  natural  resistance  to  bacterial 
invasion. 

Bacillus  of  Tetanus. — Another  organism  especially 
to  be  guarded  against  in  surgery  is  the  bacillus  of  tetanus, 
which  is  especially  liable  to  infect  wounds  of  accidental 
origin,  and  particularly  those  contaminated  by  the  soil. 
The  tetanus  bacillus  is  found  in  the  soil,  and  especially  in 


ANTISEPSIS    AND    ASEPSIS  443 

soil  covered  by  the  feces  of  herbivorous  animals.  Usually 
the  organism  gains  entrance  to  the  system  at  the  time  of 
the  accident,  but  open  wounds,  particularly  wounds  of 
the  hands  and  feet,  may  readily  become  infected  later. 
In  wounds  caused  by  blank  cartridges  the  tetanus  germ 
is  particularly  liable  to  develop.  The  source  of  the 
infection  appears  commonly  to  be  the  wad  of  the  car- 
tridge, but  the  germ  is  probably  frequently  also  present 
on  the  soiled  hands  or  clothing  of  the  victim,  and  is 
driven  in  at  the  time  of  the  accident. 

The  tetanus  bacillus  is  of  the  strict  anaerobic  variety, 
that  is  to  say,  the  absence  of  oxygen  is  essential  to  its 
development.  Punctured  wounds  and  those  caused  by 
gunshot,  both  of  which  reach  the  deeper  tissues  with  small 
external  opening,  offer,  therefore,  conditions  peculiarly 
favorable  to  the  growth  of  this  organism. 

The  tetanus  bacillus  produces  no  special  local  manifes- 
tations, but  marked  characteristic  physical  symptoms, 
the  most  important  of  which  is  the  typical  convulsion  (p. 
683) .  The  acute  form  of  this  infection  is  very  frequently 
fatal. 

Antitoxins  are  prepared  for  the  treatment  of  tetanus  and 
of  streptococcus  infections.  Their  use  is  in  vogue  at  the 
present  day.  Some  claim  markedly  favorable  results 
from  such  treatment;  others  consider  that  the  use  of  these 
preparations  is  still  largely  experimental,  and  their  value 
not  as  yet  finally  demonstrated. 

ANTISEPSIS  AND  ASEPSIS 

Antisepsis. — As  we  saw  in  the  last  chapter,  it  is  only 
of  comparatively  recent  years  that  the  sources  and  channels 
of  infection  have  been  recognized.  Following  Lister's 
deduction,  that  sepsis  and  suppuration  were  the  result  of 
the  activity  of  micro-organisms  produced  by  a  process 
strikingly  similar  to  the  familiar  phenomenon  of  fermenta- 
tion, the  efforts  of  the  surgeons  were  directed  toward 
devising  means  that  would  protect  the  tissues  from  the 
invasion  of  bacteria. 

Experiments  showed  that  certain  drugs  possessed  the 
property  of  destroying  or,  at  least,  arresting  the  activity 


444  SURGICAL   BACTERIOLOGY,   ASEPSIS 

of  these  germs.  The  use  of  such  drugs  which  were  now 
classed  as  antiseptics  in  the  preparation  of  dressings,  in 
the  cleansing  of  the  hands,  of  the  instruments  used,  and 
also  of  the  skin  of  the  field  of  operation,  and,  finally,  the 
saturation  of  the  air  during  the  operation  by  an  antiseptic 
spray,  constituted  the  practical  outcome  of  Professor 
Lister's  teaching,  and  was  known  as  the  antiseptic  method 
of  treating  wounds. 

The  antiseptics  most  in  use  were  carbolic  acid,  bichlorid 
of  mercury,  chlorid  of  lime,  chlorinated  soda,  and  iodoform, 
the  latter  as  a  powder  applied  directly  to  wounds,  and  at 
that  time  extensively  used. 

The  air  was  saturated  by  means  of  a  fine  carbolic 
steam  spray,  which  was  kept  playing  over  the  whole  field 
of  operation  during  each  operation  or  dressing.  The 
instruments  were  covered  with  carbolic  solution  some  hours 
before  each  operation  or  dressing,  and  kept  in  the  solution 
except  when  actually  in  use.  In  dressings,  the  old-fash- 
ioned poultice  or  ointment,  spread  on  lint,  was  replaced 
by  loose-meshed  gauze,  saturated  with  a  disinfectant,  and 
medicated  absorbent  cotton;  the  wound  itself  was  cleansed 
with  an  antiseptic  and  powdered  with  iodoform.  Sea- 
sponges  used  for  cleaning  were  carefully  washed  after 
use  and  kept  soaking  in  a  disinfectant.  Subsequently 
their  use  was  superseded  by  sponges  made  of  gauze  or 
cotton  and  discarded  after  use. 

The  results  of  Professor  Lister's  methods  completely 
justified  his  theories.  Epidemics  of  "hospital  fever,"  or 
blood-poisoning  from  infected  wounds,  until  then  con- 
stantly breaking  out  in  hospital  wards,  disappeared; 
wounds,  closed  at  the  time  of  operation,  healed  without 
suppuration.  It  was  demonstrated  that  the  cavities  of  the 
body  could  be  entered,  and  operations  performed  on  im- 
portant structures  without  such  a  proceeding  being  fol- 
lowed by  a  general  septic  condition.  It  is  difficult  to 
realize  that  thirty  years  ago  these  familiar  facts  were 
looked  upon  as  tentative  discoveries. 

Antiseptic  methods  spread  from  the  operating-table  to 
all  departments  connected  with  the  care  of  sick  people. 
From  disinfecting  the  air  during  an  operation,  the  necessity 


ANTISEPSIS  AND   ASEPSIS  445 

came  to  be  recognized  of  protecting  the  air  from  impurities 
by  rigid  cleanliness  and  antiseptic  principles  applied  to 
domestic  work.  Absolute  cleanliness,  no  longer  a  mere 
esthetic  principle,  was  now  recognized  as  a  practical 
necessity  in  wards,  operating-room,  and  all  departments 
of  a  hospital  for  the  prevention  of  infectious  conditions. 
Dust  and  dirt,  now  found  to  be  the  favorite  harboring 
places  of  pus-producing  germs,  were  rigorously  removed; 
in  hospital  construction  and  equipment  materials  that 
easily  absorbed  dirt  and,  therefore,  bacteria,  such  as 
unpolished  wood  for  floors  or  furniture,  wall-papers,  car- 
pets, and  hangings,  disappeared;  hard  wood  capable  of 
being  highly  polished  was  largely  used,  and  later  marble, 
cement,  glass,  or  metal,  all  presenting  hard,  smooth,  non- 
absorbent  surfaces,  were  proved  to  be  the  materials  most 
readily  kept  free  from  germs. 

The  same  principles  were  applied  to  the  clothing  worn 
by  those  attending  the  sick,  requiring  that  it  should  be 
made  of  washable  material,  especially  of  linen,  which, 
when  ironed,  prevents  a  smooth,  polished  surface,  less 
readily  absorbent  than  many  other  materials. 

Fresh  air  and  sunlight  were  proved  to  be  natural  anti- 
septics, and  were  now  freely  admitted  to  wards  and 
sick-rooms,  hitherto  most  frequently  kept  close  and 
stuffy. 

The  practice  of  disinfecting  the  air  by  means  of  the 
carbolic  spray  comparatively  soon  fell  into  disuse.  The  air 
purified  of  dust  was  found  to  be  also  freed  from  germs,  and 
it  was  not  considered  to  be  of  practical  value  to  saturate 
it  with  a  disinfectant.  Otherwise  antiseptic  principles, 
with  various  modifications  and  developments,  were  the 
accepted  methods  for  some  twenty  years.  For  the  last 
fifteen  years,  however,  asepsis  has,  at  first  gradually,  and 
later  almost  entirely,  superseded  antisepsis  by  really 
direct  logical  sequence. 

Antiseptic  methods  protected  a  wound  by  keeping  it 
constantly  surrounded  by  agents  that  destroyed  bacteria  or, 
at  least,  bacterial  activity.  It  had  certain  disadvantages : 
if  the  agents  were  used  in  sufficient  strength  adequately  to 
fulfil  their  function,  many  of  them  actually  injured  the 


440  SURGICAL   BACTERIOLOGY,   ASEPSIS 

tissues  or  the  instruments,  etc.,  used,  and  others  had  a  toxic 
effect  on  the  system. 

Asepsis. — The  method  we  know  as  asepsis  (literally, 
without  poison)  was  developed  from  the  principle  that 
contamination  of  a  wound  came  from  without;  therefore, 
if  a  wound  were  protected  from  contamination,  there  would 
be  no  development  of  manifestations  attributable  to  germ 
activity,  and  it  would  not  be  necessary  to  apply  antiseptics 
to  the  wound  itself. 

To  attain  this,  the  room  in  which  the  wound  is  to  be 
exposed  must  be  free  from  germs  and  of  dust,  which  is 
the  common  carrier  of  germs;  the  instruments  and  dress- 
ings, the  hands  of  the  operator  and  assistants,  every- 
thing, in  fact,  that  might  come  into  direct  or  indirect 
contact  with  the  wound,  must  be  made  free  from  bacterial 
invasion  and  kept  so  during  the  entire  time  the  wound 
should  be  exposed. 

An  illustration  may  serve  to  make  clear  the  similarity 
of  principle  and  the  difference  in  methods  in  antiseptic 
and  aseptic  surgery. 

Suppose  a  hall  filled  with  treasure  and  invaded  by  a 
band  of  thieves,  who  will  destroy  and  carry  off  the  treasure; 
let  us  take  the  hall  and  its  treasure  as  representing  the 
wounded  tissues,  and  the  band  of  thieves  as  a  horde  of 
bacteria.  Now,  let  us  imagine  that  the  thieves  have  been 
followed  by  a  guard  sufficient  in  numbers  and  force  to 
hold  the  thieves  in  check.  The  treasure  is,  for  the  time 
being,  safe,  and  will  remain  so  as  long  as  the  guard  is 
stronger  than  the  thieves.  This  we  may  take  as  repre- 
senting the  antiseptic  principle. 

The  aseptic  principle  may  be  demonstrated  by  pictur- 
ing the  same  hall  into  which,  by  vigilant  care  outside  the 
door,  thieves  have  not  been  allowed  to  enter.  There  are 
no  thieves,  no  guard  is  necessary;  but  if  vigilance  is  re- 
laxed, if  one  gate  of  admission  is  unprotected,  the  hall 
lies  completely  at  the  mercy  of  the  invading  band.  To 
carry  the  illustration  a  little  further,  the  gates  of  admission 
are  represented  by  the  instruments,  dressings,  and  all  so- 
lutions or  apparatus  that  come  in  contact  with  the  wound, 
by  the  hands  of  the  operator  and  all  who  assist  at  the 


STERILIZATION  447 

operation,  by  the  surrounding  air,  and  by  the  surface  of 
the  skin  covering  the  area  of  operation. 

It  is  necessary  that  these  should,  in  the  first  place, 
themselves  be  free  from  bacteria,  and  that,  once  rendered 
free,  they  should  be  kept  in  this  condition  all  the  time 
the  wound  is  exposed. 

STERILIZATION 

Substances  or  bodies  entirely  free  from  bacteria  are  said 
to  be  sterile,  and  the  process  by  which  they  are  rendered 
so  is  called  sterilization. 

While  antiseptic  methods  obtained  in  surgery,  steriliza- 
tion was  carried  out  entirely  by  the  use  of  chemical  agents, 
that  is  to  say,  by  the  use  of  antiseptics,  in  most  cases 
producing  not  true  sterilization,  but  merely  a  partial 
or  temporary  arrest  of  bacterial  activity.  In  developing 
aseptic  methods  in  surgery  from  the  antiseptic  methods, 
the  limitations  of  chemical  sterilization  were  recognized  as 
a  stumbling-block,  and  attention  was  turned  to  more 
effectual  and  reliable  means  of  accomplishing  the  desired 
result. 

Sterilization  by  Heat. — For  instruction,  the  surgeons 
turned  to  the  bacteriologic  laboratories.  It  was  found  that 
even  highly  resistant  bacteria  could  be  destroyed  by  being 
subjected  to  a  high  temperature  for  a  definite  period. 
In  the  laboratories  sterilization  was  accomplished  by  the 
actual  flame,  by  baking,  by  boiling,  and  by  steam.  In- 
genuity set  to  work  to  devise  means  by  which  perishable 
substances,  such  as  dressings  and  delicate  instruments, 
could  be  brought  to  the  necessary  temperature  without 
being  burnt  or  otherwise  destroyed.  As  results,  we  have 
the  varieties  of  sterilizing  apparatus  familiar  at  the 
present  day  in  modern  surgical  methods. 

It  is  interesting,  in  this  connection,  to  realize  that  in  the 
early  laws  of  the  children  of  Israel  the  purifying  property 
of  heat  was  recognized.  We  read  in  the  book  of  Numbers 
(Ch.  xxxi,  23):  "Everything  that  may  abifle  the  fire  ye 
shall  make  go  through  the  fire  and  it  shall  be  clean,"  and, 
it  is  added,  "  all  that  abideth  not  the  fire  ye  shall  make 
go  through  the  water." 


448  SURGICAL   BACTERIOLOGY,   ASEPSIS 

Actual  Flame. — Sterilization  by  the  actual  flame  is  the 
least  used  form  of  sterilization.  It  is  applicable  to  small 
articles,  such  as  needles,  platinum  wires,  cautery-tips, 
etc.,  which  can  be  made  red  hot  without  melting.  An 
alcohol  lamp  or  a  Bunsen  gas-burner  is  used  for  the  pur- 
pose, the  flame  of  either  being  free  from  soot  or  impurities 
that  would  adhere  to  the  article  sterilized. 

Boiling  was  found  a  practical  method  of  sterilizing,  and 
was  at  once  adopted  for  fluids,  for  instruments,  basins,  and 
vessels  of  metal,  china,  or  glass,  and  all  substances  where 
boiling  is  practical. 

Boiling,  to  be  effectual,  must  be  done  in  a  closely  covered 
vessel,  containing  sufficient  water  completely  to  cover 
the  articles  to  be  sterilized.  The  time  necessary  for  com- 
plete sterilization  is  usually  considered  to  be  fifteen  min- 
utes of  actual  boiling.  Fifteen  minutes  is,  however,  too 
long  for  some  articles  that  stand  boiling  badly,  such  as 
rubber  goods  or  fine  sharp  instruments,  which  become 
blunted  in  the  process. 

These  articles  are  capable  of  being  thoroughly  cleansed 
previously  of  all  deposits  which  might  contain  bacteria 
and  greasy  substances  to  which  bacteria  would  readily 
adhere.  Needles  and  knives  which  are  made  of  highly 
polished  metal  without  joints  or  grooves,  are  usually 
boiled  for  only  thirty  seconds,  and  rubber  goods  or  sharp 
instruments  that  have  grooves  or  joints,  from  three  to 
five  minutes  (Chapter  XIII).  Practically,  these  articles 
are  better  sterilized  by  chemical  means. 

Baking,  or  sterilization  by  dry  heat,  was  the  earliest 
method  employed  in  the  sterilization  of  dressings,  cloth- 
ing, and  all  varieties  of  "  dry-goods."  A  hot-air  chamber 
was  used,  somewhat  similar  in  principle  to  an  oven.  It 
consisted  of  a  strong  iron  box  with  double  walls,  provided 
with  a  closely  fitting  iron  door;  the  space  between  the  walls 
formed  an  air-chamber  in  which  the  hot  air  was  kept 
circulating.  In  institutions  such  a  chamber  was  frequently 
built  near  a  furnace,  with  which  it  was  connected  as  an 
ordinary  oven  is  with  the  kitchen  stove.  These  chambers 
were  frequently  of  considerable  size,  and  were  used  for 
the  disinfection  of  mattresses,  blankets,  and  the  clothing  of 


STERILIZATION 


449 


infectious  cases.  Articles  were  baked  for  one  hour  at 
temperatures  not  below  150°  C.  (302°  F.).  With  so  long 
an  exposure  to  dry  heat,  however,  perishable  materials 
were  scorched  and  burned,  so  that  the  method  had  great 
disadvantages. 

Moist  Heat. — Sterilization  by  dry  heat  was  quickly 
replaced  by  sterilization  by  moist  heat;  in  other  words, 
by  steam.  Moist  heat  is  more  penetrating  than  dry,  is 
not  destructive  to  the  extent  of  dry  heat,  and  was  proved 
to  destroy  bacteria  as  effectually  and  in  a  shorter  time, 
fifteen  to  twenty  minutes 
being  sufficiently  long  for  the 
destruction  of  highly  resistant 
bacteria. 

Since  its  introduction,  ster- 
ilization by  steam  heat  has 
replaced  all  other  forms, 
wherever  practical,  and  its 
use  at  the  present  day  is 
universal. 

Two  methods  of  using 
steam  are  employed — steam 
just  as  it  is  generated  by 
boiling,  and  steam  under 
pressure. 

Arnold  Sterilizer.  —  The 
apparatus  most  commonly  in 
use  for  sterilizing  by  steam 
without  pressure  is  the  Arnold 
sterilizer. 


Fig.  148. — Arnold's  steam  ster- 
ilizer. 


This  is  a  simple  apparatus  in  three  parts — the  sterilizing 
chamber,  the  jacket,  and  the  water  chamber. 

The  sterilizing  chamber  is  a  cylindric  metal  box,  usually 
of  copper,  completely  inclosed  in  a  movable  outer  covering 
of  the  same  metal,  which  forms  the  jacket;  the  whole 
fits  closely  over  a  wide  copper  pan  filled  with  water,  from 
which  the  steam  is  generated,  forming  the  water  chamber. 
The  bottom  of  the  sterilizing  chamber  is  provided  with  an 
opening  through  which  the  steam  is  introduced.  The 
articles  to  be  sterilized  are  packed  on  a  perforated  metal 

29 


450       SURGICAL  BACTERIOLOGY,  ASEPSIS 

tray  in  the  bottom  of  the  chamber;  the  perforations 
allow  the  steam  to  percolate  freely  to  all  parts.  Between 
the  sterilizing  chamber  and  the  inclosing  jacket  a  small 
air-space  is  left,  which  has  two  uses:  First,  it  helps 
in  maintaining  an  even  temperature  in  the  sterilizing 
chamber;  second,  the  steam,  coming  in  contact  with  the 
top  of  the  covering,  condenses,  the  water  trickles  down 
the  sides  of  the  jacket  in  the  air-space,  and  returns  to 
the  water  chamber  through  some  small  perforations  at  the 
bottom,  thus,  to  a  certain  extent,  replacing  the  water 
that  has  been  converted  into  steam.  The  whole  apparatus 
may  be  placed  over  a  portable  gas  stove  or  on  the  kitchen 
stove. 

Improvised  Steam  Sterilizer. — An  adequate  steam  ster- 
ilizer may  be  made  with  a  clothes-boiler.  About  a  fourth 
of  the  depth  is  filled  with  water,  above  which  the  articles 
are  suspended  in  an  improvised  hammock  of  net  or  muslin, 
fastened  by  strings  to  the  outside  handles.  If  the  boiler 
is  to  be  permanently  devoted  to  the  purpose,  it  is  worth 
while  to  have  it  fitted  with  a  shelf  or  tray  of  perforated 
metal,  which  can  be  hung  from  two  hooks  attached  to-  the 
rim  of  the  boiler.  If  dressings  sterilized  in  this  manner 
become  wet,  they  should  be  dried  at  once  in  an  oven. 

In  sterilizing  with  steam  by  this  method  thirty  minutes 
should  be  allowed,  counting  from  the  time  the  steam  is 
generated.  It  must  be  remembered  that,  although  bac- 
teria are  destroyed  at  a  temperature  of  100°  C.,  spores  are 
not. 

The  Autoclave. — Steam  under  pressure  can  be  raised 
to  a  higher  temperature  than  steam  generated  at  the  ordi- 
nary pressure  of  the  atmosphere.  France  was  the  first 
country  to  adopt  sterilization  under  pressure,  and  in- 
vented the  apparatus  known  as  the  autoclave,  now  in 
universal  use  in  some  form  or  other. 

Whatever  the  shape  or  size  of  the  autoclave,  it  consists 
essentially  of  three  chambers:  (1)  A  closed  water  chamber, 
communicating  with  (2)  a  closed  steam  chamber,  which  is 
usually  in  the  form  of  a  jacket,  surrounding  and  communi- 
cating with  (3)  the  sterilizing  chamber.  During  steriliza- 
tion the  sterilizing  chamber  is  completely  closed  by  a 


STERILIZATION 


451 


heavy  metal  door  screwed  down  so  securely  that  no  steam 
can  escape. 

The  communications  between  the  three  chambers  are 
guarded  by  valves  which  are  regulated  by  handles  placed 
on  the  outside  of  the 
autoclave.  The  water 
chamber  is  also  filled 
from  the  outside.  The 
steam  chamber  has  at- 
tached to  it  a  safety-valve 
to  regulate  the  pressure 
to  the  required  amount. 
For  example,  if  fifteen 
pounds'  pressure  is 
wanted,  the  valve  is  set 
so  that  any  pressure  over 
fifteen  pounds  forces  the 
valve  up  and  allows  suf- 
ficient steam  to  escape 
to  reduce  the  pressure 
again  to  fifteen  pounds. 
It  is  always  of  the  first 
importance  that  this 
valve  should  be  in  work- 
ing order. 

The  autoclave  is  also 
furnished  with  a  dial 
showing  the  pressure  of 
steam  and  the  tempera- 
ture attained,  and  with 
a  glass  gauge  by  which 
the  amount  of  water  in 
the  water  chamber  can 
be  estimated. 

The  water  in  the  cham- 
ber may  be  heated  by  gas 
placed  below  the  autoclave.  In  institutions  where  steam 
is  used  for  heating  the  autoclave  is  generally  attached 
directly  to  a  steam  pipe,  and  gas  is  then  not  necessarj7. 
The  connection  pipe  is  provided  with  a  valve  to  regulate 


149. — Autoclave, 
form. 


Horizontal 


452  SURGICAL   BACTERIOLOGY,    ASEPSIS 

the  amount  of  steam  introduced,  and  a  second  pipe  is 
necessary  to  carry  off  the  superfluous  steam. 

The  articles  to  be  sterilized  are  placed  on  perforated 
metal  shelves,  with  one  or  more  of  which  the  sterilizing 
chamber  is  provided.  In  packing  the  sterilizer  with  objects 
that  expand  under  heat,  sufficient  space  must  be  allowed 
for  such  expansion.  Two  articles  that  expand  must  not 
be  placed  near  together;  thus,  glass  flasks  or  jars  will 
crack  if  set  near  to  each  other  or  directly  on  the  metal 
shelf:  the  shelf  should  first  be  covered  with  a  towel 
folded  to  several  thicknesses. 

Printed  directions  to  be  followed  in  the  manipulation 
of  the  autoclave  or  sterilizer  should  hang  where  they  can 
readily  be  referred  to.  At  the  same  time,  the  pupils 
should  be  drilled  in  its  use,  and  have  each  part  carefully 
explained  to  them: 

The  steps  in  sterilizing  are  as  follows: 

1.  Examine  the  water-gauge,   and,   if  necessary,   add 
more  water. 

2.  Pack  the  sterilizer  and  close  the  door. 

3.  Either  light  the  gas  or  turn  on  the  steam;  then  im- 
mediately— 

4.  Open  the  valve  between  the  water  chamber  and  the 
steam  chamber. 

As  steam  is  generated,  the  needle  on  the  dial  is  seen  to 
rise.  When  it  reaches  the  desired  pressure,  and  not 
before — 

5.  Open  the  valve  between  the  steam  jacket  and  the 
sterilizing  chamber. 

This,  of  course,  reduces  the  pressure  temporarily  and 
the  needle  falls.  Sterilizing  does  not  begin  until  the  needle 
shows  a  second  time  that  the  necessary  pressure  has  been 
reached,  this  time  in  the  sterilizing  chamber. 

When  sterilization  is  complete,  the  heat  supply  is  turned 
off.  The  door  is  not,  however,  opened  until  the  needle  indi- 
cates not  more  than  five  pounds'  pressure.  If  the  door  is 
opened  at  a  high  pressure,  the  face  and  hands  may  be 
scalded,  besides  which  the  sudden  change  in  pressure  is 
liable  to  blow  the  corks  and  stoppers  or  the  contents  out 


STERILIZATION  453 

of  jars  and  bottles  containing  fluids,  and  to  cause  crack- 
ing of  glass  flasks  and  similar  objects. 

The  usual  pressure  required  is  15  Ibs.,  which  repre- 
sents a  temperature  of  120°  C.  or  248°  F.;  at  this  pressure 
sterilization  is  continued  for  fifteen  minutes. 

An  autoclave  similar  in  principle,  and  but  slightly  dif- 
ferent in  mechanism,  is  used  to  sterilize  water  where  large 
quantities  are  constantly  required.  As  the  tanks  contain- 
ing the  water  are  hermetically  closed,  water  once  sterilized 
will  remain  sterile  until  fresh  water  is  added,  after  which 
sterilization  must  be  repeated. 

A  temperature  of  120°  C.  has  a  more  powerful  effect 
on  bacteria  than  a  temperature  of  100°  C.  While  the 
lower  temperature  will  completely  destroy  fully  developed 
bacteria  in  from  fifteen  to  twenty  minutes,  it  has  no  effect 
at  all  on  the  more  resistant  spores  (p.  392).  Fifteen 
minutes  in  an  autoclave  at  15  pounds'  pressure  will,  it  has 
been  shown,  destroy  spores,  while  if  either  boiling,  dry 
heat,  or  steam  at  ordinary  atmospheric  pressure  is  used, 
the  spores  must  be  exposed  for  a  number  of  hours  before 
they  are  destroyed.  Few  of  the  substances  it  is  neces- 
sary to  sterilize  could  be  subjected  to  so  prolonged  an 
exposure  without  injury  or  completely  changing  their 
nature. 

Fractional  Sterilization. — Where  it  is  not  practical  to 
use  steam  under  pressure,  substances  in  which  spores  may 
exist  are  subjected  to  what  is  known  as  the  fractional 
method  of  sterilization.  These  are  substances  which  rep- 
resent media  in  which  bacteria  can  live  and  propagate, 
such,  for  example,  as  gelatin,  milk,  and  bouillon,  etc.,  to 
be  used  as  culture-media;  oils,  ointments;  water  to  be 
used  during  operations,  in  the  making  of  solutions,  or 
for  subcutaneous  infusion;  and  so  forth. 

By  the  fractional  method  such  articles  are  either  boiled 
or  subjected  to  steam  heat  (100°  C.)  for  fifteen  minutes  on 
three  successive  days.  At  the  first  boiling  all  fully  developed 
bacteria  are  destroyed.  The  intervening  twenty-four 
hours  is  sufficient  to  develop  most  of  the  spores,  and  as  full- 
grown  bacteria  they  are  destroyed  by  the  second  boiling. 
Any  spores  left  will  develop  between  the  second  boiling 


454  SURGICAL   BACTERIOLOGY,   ASEPSIS 

and  the  third,  at  which  any  surviving  bacteria  are  com- 
pletely destroyed.  Between  the  sterilization  the  substance 
to  be  sterilized  should  be  kept  at  a  moderately  high  tem- 
perature— about  80°  F. — to  favor  the  development  of 
the  bacteria.  Experiments  show  that  this  method  is 
sufficient  for  the  destruction  of  even  the  most  resistant 
spores. 

The  principles  that  govern  the  sterilization  of  milk 
to  be  used  as  food  are  discussed  in  the  chapter  on  Food 
Values. 

Chemical  Sterilization. — While  sterilization  by  heat,  or 
thermic  sterilization,  is  used  wherever  practical,  it  is  not 
applicable  in  all  instances.  Obviously,  for  example,  it 
cannot  be  applied  to  living  organic  tissues.  Modern 
asepsis  has,  therefore,  retained  from  the  antiseptic  meth- 
ods the  practice  of  sterilization  by  chemical  agents. 

Three  groups  of  these  chemical  agents  are  recognized, 
often  loosely  classed  as  disinfectants. 

1.  Antiseptics. — Their  action  is  to  arrest  the  activity 
and  prevent  the  development  of  bacteria. 

2.  Germicides. — These  actually  destroy  the  bacteria.   An- 
tiseptics used  in  sufficient  strength  and  over  a  sufficiently 
long  period  act  also  as  germicides.     They  cannot,  however, 
be  used  in  such  strength  on  living  tissue.    Germicides  are, 
properly  speaking,  true  disinfectants. 

3.  Deodorants. — Some  antiseptics  possess  the  property  of 
neutralizing  disagreeable  odors;  such  are  permanganate  of 
potash,  carbolic  acid,  cresol,  and  lysol.     Other  substances 
have  also  these  attributes,  but  no  antiseptic  property,  as, 
for  example,  eau  de  cologne  and  toilet  waters. 

Antiseptics  are  used  in  the  form  of  solutions,  powders, 
ointments,  and  vapors  or  fumes. 

ANTISEPTICS  IN   GENERAL  USE 

For  convenience,  all  forms  of  antiseptics  in  use  will  be 
considered  together,  as  well  as  those  especially  in  use  for 
sterilizing  in  surgical  work.  The  following  are  the  prin- 
cipal antiseptics  in  common  use. 

Bichlorid  of  Mercury  or  Corrosive  Sublimate  (Hydrar- 
gyrum Chloridum  Corrosivum). — A  white,  highly  poisonous 


ANTISEPTICS    IN    GENERAL    USE  455 

powder,  soluble  in  cold  water,  precipitated  by  the  action 
of  chlorid  of  sodium  on  the  bisulphid  of  mercury.  This 
is  the  most  constantly  used  antiseptic  in  surgical  work, 
but  presents  certain  disadvantages,  as  follows: 

1.  It  is  inert  in  the  presence  of  albumins  or  of  alkalis: 
it  is,  therefore,  (a)  not  a  perfect  disinfectant  for  organic 
secretions,  such  as  excreta,  etc.,  and  (6)  it  is  useless  if 
mixed  with  soap,  as  for  cleansing  purposes. 

2.  It  does  not  penetrate  oily  substances :  to  act,  therefore, 
on  the  skin,  all  grease  must  first  be  removed. 

3.  On  raw  surfaces  it  is  to  some  extent  an  irritant;  it  is 
considered  to  destroy  cells  and  promote  exudation,  thus 
indirectly  lessening  resistance  to  infection;  many  surgeons, 
therefore,   do   not  use   bichlorid   of   mercury   for    clean 
wounds. 

4.  Unless  very  highly  diluted  it   is  too  irritating  for 
delicate  tissues,  such  as  the  serous   membranes  and  the 
conjunctiva. 

5.  Mucous  membrane  surfaces  are  made  dry  and  rigid 
by  solutions  of  the  usual  strength.     It  is  not,  therefore, 
suitable  for  douching  in  obstetric  cases,  where  the  parts 
must  be  kept  flexible  and  lubricated  during  parturition. 

6.  If  too  freely  absorbed  through  the  tissues,  it  causes 
mercurial  poisoning. 

7.  It   stains   white   materials   yellow,   discolors   paint, 
and   to  some  extent  corrodes  metal,  wood,  marble,  and 
porcelain. 

8.  In  many  persons  the  constant  external  use  of  bichlorid 
of  mercury  produces  a  skin  eruption  difficult  to  cure. 

The  action  of  bichlorid  of  mercury  in  the  presence  of 
albumin,  which  is  constantly  present  in  all  organic  tissues, 
excreta,  etc.,  is  to  coagulate  the  albumin,  thus  forming  a 
covering  impenetrable  to  the  disinfectant,  inside  which 
bacteria  can  live.  This  disadvantage  is  overcome  by 
the  addition  of  common  salt,  chlorid  of  ammonia,  or  some 
simple  acid,  such  as  tartaric  acid.  The  "  bichlorid  tablets  " 
in  common  use  contain  7.3  of  corrosive  sublimate  and  the 
same  amount  of  chlorid  of  ammonia.  One  tablet  dissolved 
in  one  pint  of  water  makes  a  solution  of  bichlorid  of  mer- 
cury 1  :  1000. 


456  SURGICAL   BACTERIOLOGY,   ASEPSIS 

The  average  strength  in  which  bichlorid  of  mercury  is 
used  is  as  follows: 

For  sterilizing  china,  glass,  etc.,  where  steam  is 
not  used 1 : 500. 

For  disinfecting  the  skin 1 : 1000  to  1 : 2000. 

For  dressing  and  cleansing  infected  wounds .  .  1 : 2000  to  1 : 3000. 

For  vaginal  douching  and  disinfecting  mucous 
membrane  surfaces 1 : 4000  to  1 : 5000. 

For  irrigation  of  sensitive  membranes,  such  as 
the  conjunctiva,  urethra,  etc 1 : 10,000  to  1:  40,000. 

Bichlorid  of  mercury  in  a  strong  solution  (1  : 500  to 
1  :  1000)  is  frequently  used  to  destroy  pediculi  that  infest 
the  human  hair. 

Carbolic  acid,  or  phenol,  is  a  coal-tar  derivative,  ob- 
tained as  crystals  which  become  liquefied  on  the  addition 
of  5  per  cent,  cold  water;  the  liquefied  crystals  are  known 
as  pure  carbolic  acid. 

Pure  carbolic  is  not  used  unless  as  a  local  application  in 
the  treatment  of  badly  infected  wounds.  If  the  wound  is 
extensive,  the  application  is  usually  followed  in  a  few 
minutes  by  a  washing  with  alcohol,  which  arrests  the 
action  of  the  acid.  For  ward  use  the  standard  solution  of 
carbolic  acid  is  usually  1  part  carbolic  in  20  parts  water, 
familiarly  referred  to  as  "  one  in  twenty." 

As  carbolic  acid  does  not  stain  linen,  discolor  paint,  or 
injure  wood  or  metals,  it  is  a  good  disinfectant  in  many 
circumstances.  In  common  with  other  acids  it  will, 
however,  injure  marble.  On  account  of  its  poisonous 
properties  it  cannot  be  used  in  dressings  where  the  sur- 
face is  extensively  denuded,  as  in  burns  and  scalds,  since 
poisons  may  be  absorbed  through  the  broken  skin. 

The  oily  liquid  of  pure  carbolic  acid  does  not  mix  readily 
with  water.  It  should  be  shaken  in  a  bottle  or  stirred 
until  entirely  dissolved,  otherwise  any  tissue  coming  in 
contact  with  the  pure  carbolic  will  be  burned.  Should  a 
burn  be  caused  in  this  way,  the  area  should  be  immediately 
washed  with  the  antidote,  alcohol;  care  must  also  be  taken 
to  use  neither  oil  nor  ointment  in  the  immediate  dressing 
of  such  a  burn,  since  oils  aid  in  the  absorption  of  the 
carbolic  acid.  Salt  solution  or  a  sterile  dusting-powder 
is  the  dressing  generally  used. 


ANTISEPTICS    IN   GENERAL   USE  457 

The  average  strength  in  which  carbolic  acid  solution  is 
used  is  as  follows: 

For  instruments  and  hardware 1 : 20. 

For  the  skin  and  for  linen  and  clothing 1 : 40  to  1 : 60. 

For  vaginal  douching  or  in  dressing  of  wounds ...  1 : 80. 

For  sensitive  membranes,  conjunctiva,  etc 1 : 100  or  weaker. 

In  isolating  an  infectious  case  a  sheet  wrung  out  of 
carbolic  acid  1  :  20,  and  kept  well  sprinkled  with  the  same, 
may  be  hung  across  the  doorway,  and  arrests  the  passage 
of  germ-laden  dust  to  the  rest  of  the  house. 

Carbolic  acid  acts  to  some  extent  as  a  local  anesthetic. 
Its  use  as  a  disinfectant  for  the  hands  causes  frequently  an 
unpleasant  numbness.  This  property  makes  it  a  soothing 
application  for  such  skin  affections  as  urticaria,  the  rash 
of  poison  ivy,  etc. 

Carbolic  crystals  may  be  vaporized  by  placing  them  on  a 
heated  metal  plate  over  a  lamp,  or  by  wrapping  them  in 
brown  paper  and  setting  it  alight;  in  this  way  they  are 
sometimes  used  to  disinfect  the  air  of  a  sick-room.  Bowls 
of  carbolic  acid  solution  placed  about  a  sick-room  act  also 
to  a  limited  extent  as  a  disinfectant. 

On  account  of  its  irritating  properties  on  the  tissues  and 
of  its  ready  absorption  into  the  system,  carbolic  acid  is 
not  commonly  used  for  wounds  or  for  mucous  membrane 
surfaces.  For  the  latter  use  two  other  coal-tar  derivatives 
are  generally  preferred,  lysol  and  creolin. 

Lysol  is  obtained  by  the  action  of  nascent  soap  on 
cresol,  a  derivative  of  carbolic  acid.  Mixed  with  water,  it 
forms  a  soapy  liquid.  This  makes  it  peculiarly  useful  for 
douching,  especially  in  obstetric  work,  as  it  also  acts  as  a 
lubricant.  It  is  used  for  vaginal  douching  and  for  the 
hands  in  a  solution  of  1  to  2  per  cent.  For  infected 
conditions,  3  per  cent,  solution  is  generally  used. 

Creolin  is  an  emulsion  of  cresol,  and  has  high  anti- 
septic value;  it  is  also  a  deodorant,  and  to  some  extent 
a  hemostatic.  Mixed  with  water,  it  forms  a  milky  solu- 
tion. It  is  a  popular  antiseptic  in  the  treatment  of 
infectious  wounds,  and  as  a  rectal  disinfectant  in  a  solution 
of  1  to  2  per  cent.  Creolin  is  the  antiseptic  generally  pre- 


458  SURGICAL   BACTERIOLOGY,    ASEPSIS 

ferred  in  rectal  surgery.  Gauze  which  in  preparation  has 
been  saturated  with  creolin  (5  to  10  per  cent.)  is  also  used 
in  surgical  dressings. 

Boric  acid  or  boracic  acid  (acidutn  boricum)  comes  in 
white  crystals,  generally  obtained  by  the  action  of  sul- 
phuric acid  on  borax.  The  crystals  are  soluble  in  25  parts 
of  cold  water  or  in  3  parts  of  hot  water.  It  is  a  mild  anti- 
septic, non-irritating  to  the  tissues,  and,  therefore,  pre- 
ferred for  delicate  or  specially  absorbent  tissues,  or  where 
large  areas  are  denuded.  It  is  the  antiseptic  generally 
used  in  the  treatment  of  the  eye,  ear,  nose,  mouth,  and 
bladder.  The  dry  powder  mixed  with  an  equal  quantity 
of  talcum  or  starch  powder  is  used  as  a  dusting-powder  for 
broken  surfaces. 

A  saturated  solution  of  boric  acid  in  water  has  a  strength 
of  4  per  cent.,  or  1 : 25.  The  saturated  solution  diluted  with 
an  equal  quantity  of  water,  making  a  solution  of  2  per  cent., 
or  1  :  50,  is  the  usual  strength  preferred  for  douching, 
irrigating,  etc. 

Hydrogen  peroxid  or  solution  of  hydrogen  peroxid  (aqua 
hydrogenii  dioxidi,  a  watery  solution  of  the  dioxid  of 
hydrogen)  is  greatly  in  favor  at  the  present  day  for  the 
cleansing  of  suppurating  wounds  and  in  the  treatment  of 
infected  conditions  of  the  throat,  mouth,  etc.  When 
brought  in  contact  with  a  suppurating  area,  oxygen  is  set 
free  and  an  effervescence  produced,  which  has  the  effect 
of  carrying  off  dead  tissue  and  inflammatory  products.  It 
is  considered  to  act  by  destroying  the  food  on  which  bac- 
teria live.  Usually  it  is  diluted  to  half  its  strength  with 
sterile  water,  or,  if  used  as  a  throat  spray  or  mouth-wash, 
with  lime-water.  In  cleansing  a  wound  a  small  quantity  is 
taken  in  a  glass  syringe  and  injected  into  the  cavity. 
Peroxid  of  hydrogen  is  not  suitable  for  douching  or  the 
irrigation  of  large  surfaces.  It  should  also  be  remembered 
that  the  volume  of  gas  liberated  is  considerable,  and  for 
this  reason  peroxid  of  hydrogen  must  be  used  with  caution 
in  irrigating  sinuses  or  deep  wounds  not  well  open  to  the 
surface. 

Permanganate  of  potash  (potassii  permanganas)  occurs 
as  royal  purple  crystals,  soluble  in  16  parts  of  cold  water. 


ANTISEPTICS   IN   GENERAL    USE  459 

As  a  saturated  solution,  it  is  used  in  disinfecting  the  hands 
and  skin  by  the  Kelly  method  (p.  472).  As  a  deodorizer 
and  mild  antiseptic  it  is  used  in  irrigating  offensive  wounds 
and  cavities,  in  strength  of  from  1  to  5  per  cent.  As 
the  crystals  are  readily  carried  about,  permanganate  of 
potash  is  a  popular  antiseptic  for  douching,  etc.,  in  district 
work.  Vessels  containing  a  strong  solution  of  this  disin- 
fectant may  be  set  about  a  sick-room  to  neutralize  offen- 
sive odors. 

Alcohol,  absolute  alcohol,  containing  99  per  cent,  pure  alco- 
hol to  1  per  cent,  water,  is  not  used  except  for  pharmaceuti- 
cal or  laboratory  purposes.  Pure  alcohol  is  94.9  per  cent, 
pure  ethyl  alcohol  by  volume,  with  5. 1  per  cent,  water.  For 
surgical  uses  a  solution  of  70  per  cent,  alcohol  in  water  is 
considered  sufficient  and  by  many  preferred,  as  less  readily 
causing  coagulation  of  albumins,  which  to  some  extent 
limit  the  utility  of  alcohol  as  a  disinfectant.  Alcohol  is 
used  in  surgery  to  preserve  organic  material,  such  as  cat- 
gut, or  specimens  of  organic  tissues,  in  the  sterilization 
of  fine  needles  and  delicate  knives  after  boiling  for  thirty 
seconds;  and  for  the  removal  of  fat  and  grease  from  the 
skin  before  bichlorid  of  mercury  is  applied  (see  above). 
For  this  latter  purpose  ether  is  also  used.  Proof  spirit, 
equal  parts  of  alcohol  and  water,  or  dilute  alcohol,  about 
48  per  cent,  alcohol  in  water,  are  used  in  nursing,  chiefly 
in  giving  alcohol  rubs  and  not  for  purposes  of  disinfection. 

lodoform. — lodoform  is  obtained  as  fine  yellow  crystals, 
precipitated  by  heating  iodin  with  potassium  carbonate, 
alcohol,  and  water.  The  crystals  have  a  characteristic 
permeating  odor,  very  disagreeable  to  most  people, 
lodoform  checks  the  growth  of  bacteria  by  the  formation 
of  iodin,  which  takes  place  when  iodoform  comes  in  con- 
tact with  the  secretions  from  wounds.  The  action  of 
the  iodin  also  stimulates  the  growth  of  fibrous  tissue,  so 
important  in  the  healing  of  the  sinuses  and  cavities  of 
tubercular  lesions.  From  this  property  it  has  its  chief 
use  in  the  treatment  of  tubercular  wounds.  lodoform  is 
used  as  a  dusting-powder  for  raw  surfaces,  as  an  emulsion, 
usually  with  glycerin,  in  the  treatment  of  tubercular 
sinuses,  or  as  a  dressing  in  the  form  of  iodoform  gauze. 


460  SURGICAL   BACTERIOLOGY,   ASEPSIS 

In  rectal  lesions,  especially  also  those  of  tubercular  origin, 
it  is  applied  in  the  form  of  a  suppository  or  as  an  ointment. 

Like  peroxid  of  hydrogen,  iodoform  is  active  only  in 
contact  with  wound  secretions.  In  its  dry  state,  in  com, 
mon  with  other  dusting-powders,  iodoform  should  be 
sterilized  before  using,  as  it  may  become  contaminated 
by  bacteria  (p.  495) . 

Acetanilid  (acetanilidum),  a  carbon  compound,  is  used 
to  some  extent,  in  the  form  of  fine  white  crystals,  as  an 
antiseptic  dusting-powder  for  raw  surfaces,  to  stimulate 
indolent  secretions.  It  should  be  used  with  caution,  es- 
pecially with  children  and  feeble  persons,  as  it  is  quite  apt 
to  be  absorbed  from  the  broken  surface,  producing  danger- 
ous collapse. 

A  compound  antiseptic  dusting-powder  with  stimulating 
properties  is  composed  of  equal  parts  of  boric  acid  powder, 
bismuth  subnitrate,  and  calomel.  It  is  familiarly  known 
as  B.  B.  C.  powder. 

Blue  stone,  or  sulphate  of  copper  (cupri  sulphas),  and 
nitrate  of  silver  stick,  or  lunar  caustic  (argenti  nitras 
Jusus),  are  used  as  local  applications  to  wounds,  to  stimu- 
late indolent  granulations,  and  to  destroy  those  that  are 
redundant.  They  also  possess  antiseptic  properties. 
For  delicate  membranes,  such  as  the  conjunctiva,  a  milder 
form  of  the  silver  stick  is  used,  known  as  mitigated  silver 
stick.  A  solution  of  nitrate  of  silver  in  water,  2,  4,  and 
8  per  cent.,  is  also  used,  especially  in  the  treatment  of 
ulcerated  conditions  of  the  mucous  membranes,  in  purulent 
ophthalmia,  and  in  many  infected  conditions  of  the  throat. 
Common  salt  in  water  is  used  as  a  local  antidote,  if 
necessary.  The  action  of  these  applications  is  strictly 
local.  A  shallow  slough  forms  at  the  point  of  contact, 
which,  on  separating,  should  leave  a  healthy  granulating 
surface. 

Normal  Salt  Solution. — A  solution  of  common  salt  in 
water  is  so  called  because  the  proportion  of  salt  in  the 
fluid  is  the  same  as  that  in  the  blood.  It  is  in  common  use 
at  the  present  day  as  a  substitute  for  irritating  antiseptics, 
its  action  being  mildly  antiseptic  and  stimulating.  In 
this  respect  it  may  be  used  in  dressing  wounds  where  tho 


ANTISEPTICS    IN    GENERAL    USE  461 

surface  is  extensively  denuded,  as  in  burns,  in  douching  or 
irrigating  the  bladder,  vagina,  or  rectum.  Some  surgeons 
use  it  in  operations  involving  the  serous  membranes, 
especially  in  irrigating  the  peritoneal  cavity.  For  these 
purposes  it  is  preferable  to  plain  sterile  water,  which  has 
a  macerating  effect  on  the  tissue.  The  most  important 
use,  however,  is  to  restore  fluid  to  the  body  after  hemor- 
rhage, etc.,  or  as  general  stimulant  in  conditions  of  lowered 
vitality.  (See  Enemata,  Hypodermoclysis,  Intravenous 
Infusion.) 

The  standard  strength  of  normal  salt  solution  at  the 
present  day  is  T90  of  1  per  cent,  that  is,  9  in  1000,  or  nine 
grams  of  salt  to  the  liter  of  water  (2,\  drams  to  the  quart). 
Formerly  the  standard  was  T%  of  1  per  cent. 

In  making  the  solution  sterile  filtered  water  and  common 
table-salt  are  used.  The  solution  is  filtered  through  filter- 
paper  into  sterile  glass  flasks,  free  from  the  least  speck  of 
dust  or  foreign  particles.  The  filtering  is  repeated  until 
not  the  smallest  sediment  can  be  detected.  The  flask 
is  filled  two-thirds  full  and  plugged  with  sterile  cotton 
bound  securely  into  place  with  a  bandage,  which  serves  also 
to  prevent  dust  settling  on  the  rim  of  the  flask.  The 
solution  is  then  sterilized  either  in  the  autoclave  or  by 
boiling  by  the  fractional  method. 

Whitewash,  or  milk  of  lime,  made  by  mixing  one  part 
of  slaked  lime  in  four  parts  of  cold  water,  is  frequently 
a  convenient  domestic  disinfectant,  especially  for  the  walls 
of  dwellings  in  which  infectious  maladies  have  occurred. 
It  is  also  used  as  a  disinfectant  for  the  excreta  (see 
below). 

Milk  of  lime  is  best  freshly  made:  at  most  it  should 
not  stand  more  than  two  days. 

Chlorin,  a  non-metallic  element  obtained  from  sea-salt, 
is  a  greenish-yellow  gas  with  a  penetrating,  pungent 
odor,  highly  irritating  to  the  mucous  membrane  of  the 
air-passages.  It  has  powerful  antiseptic  properties.  As 
a  gas,  it  is  used  to  a  limited  extent  in  disinfecting  dwellings 
(see  below).  Chlorin  is  soluble  in  water  in  the  proportion 
of  2  parts  gas  to  1  of  water:  it  forms  the  antiseptic 
principle  in  chlorinated  lime  and  Labarraque's  solution. 


462  SURGICAL   BACTERIOLOGY,   ASEPSIS 

Chlorinated  lime  (incorrectly  known  as  chlorid  of  lime) 
is  a  white  salt,  formed  by  the  action  of  chlorin  on  slaked 
lime.  A  solution  of  the  salt  in  cold  water  is  used  for 
disinfecting  purposes.  In  mixing,  a  wooden  vessel  should 
be  used,  on  account  of  the  strong  corrosive  action  of  the 
mixture.  The  solution  is  used  in  two  strengths.  For 
the  disinfection  of  excreta  (see  below)  one  pound  is  mixed 
with  one  gallon  of  water  (10  per  cent) ;  for  other  purposes 
the  strength  is  6  ounces  to  the  gallon  (3  per  cent.),  some- 
times known  as  "  American  standard."  The  latter  is 
used  in  the  disinfection  of  closets,  sinks,  garbage-cans,  etc. 
Chlorinated  lime  is  irritating  to  the  tissues  and  destroys 
fabrics;  its  uses  as  an  antiseptic  are,  therefore,  limited. 
If  no  better  disinfectant  is  available  for  the  disinfection 
of  clothing,  the  solution  (3  per  cent.)  should  be  strained, 
and  the  clothes  rinsed  in  cold  water  after  they  have  been 
immersed  in  the  disinfectant  not  more  than  four  hours. 
In  combination  with  carbonate  of  soda  a  paste  of  chlorin- 
ated lime  is  used  by  some  in  the  surgical  preparation  of 
the  hands  (p.  473). 

Labarraque's  solution,  or  solution  of  chlorinated  soda, 
is  a  greenish-yellow  liquid  with  a  mild  odor  of  chlorin; 
its  composition  is  sodium  carbonate  10  parts,  and  chlo- 
rinated lime  8  parts,  in  100  parts  of  water.  It  is  also 
used  in  the  disinfection  of  closets  and  sinks,  etc.  In 
ward  work  it  is  often  found  useful  in  removing  stains 
from  bath-tubs,  sinks,  and  glassware.  It  is  too  destruc- 
tive to  be  used  in  disinfecting  fabrics. 

Formaldehyd,  a  gas  obtained  by  the  oxidation  of 
wood-alcohol,  has  powerful  antiseptic  and  germicidal 
properties.  A  40  per  cent,  solution  of  the  gas  in  water  is 
known  as  formalin.  A  4  per  cent,  solution  of  formalin 
in  water  is  considered  to  equal  in  antiseptic  value  a  1 : 1000 
solution  of  bichlorid  of  mercury  or  of  1 : 20  carbolic  acid. 
Cold  water  is  used  in  making  formalin  solutions,  as  the  gas 
is  given  off  if  heated.  Formalin  injures  metals  to  some 
extent,  but  at  the  present  day  is  a  popular  disinfectant 
for  linen,  clothing,  utensils,  rubber  goods,  and  all  kinds 
of  hardware  (furniture,  etc.).  A  2  per  cent,  solution  is 
generally  used.  The  vapor  is  highly  irritating  to  the  air- 


ANTISEPTICS    IN    (SEXERAL    USE  403 

passages  and  to  the  eyes,  which  to  many  is  an  objection 
to  its  use. 

Other  antiseptics  are  not  in  general  use,  but  are  fre- 
quently met  with  in  surgical  work  and  preferred  by  certain 
surgeons. 

Harrington's  iodin  solution,  a  solution  of  tincture  of 
iodin  in  water,  is  used  as  an  antiseptic  in  a  strength  of 
from  1  :  100  to  1  :  500,  especially  in  the  disinfection  of  the 
skin. 

Harrington's  alcoholic  solution  of  bichlorid  of  mercury 
is  frequently  used  in  the  preparation  of  the  skin  and  for 
disinfecting  glass,  china,  or  enamelware  by  immersion. 

This  formula  is: 

Bichlorid  of  mercury 1.5  gm. 

Hydrochloric  acid 100  c.c. 

Glycerin 100  c.c. 

Alcohol 1200  c.c. 

Distilled  water 2000  c.c. 

It  is  used  undiluted. 

Thiersch's  solution  is  made  of  boric  acid,  1|  ounces, 
salicylic  acid,  2  drains,  to  1  gallon  of  hot  water.  The 
solution  is  sterilized  before  using.  It  is  used  chiefly  for 
douching  and  irrigation  in  place  of  boric  acid  solution. 

A.  B.  C.  antiseptic  douche  contains  alum,  1  ounce, 
boric  acid,  4  ounces,  carbolic  acid  crystals,  3  drams,  and 
oil  of  peppermint,  1|  drams.  One  dram  of  the  powder  is 
used  in  one  pint  of  water.  It  is  used  chiefly  in  gynecologic 
work  as  an  antiseptic  vaginal  douche. 

Precautions. — It  must  be  remembered  that  practically 
all  disinfectants  are  highly  poisonous,  and  care  must  bt, 
taken  to  prevent  accidents  in  their  use.  The  bottles  in 
which  they  are  put  up  are  usually  of  dark  glass,  and  ribbed 
as  an  additional  precaution;  they  should  always  carry  a 
poison  label  in  a  prominent  part. 

In  hospital  work  it  is  often  the  custom  to  color  the 
solutions  commonly  used  with  one  or  other  of  the  anilin 
dyes.  Thus,  bichlorid  of  mercury  may  be  lavender, 
carbolic,  blue,  and  so  forth.  This  is  a  specially  useful 
precaution  with  those  antiseptics  that  are  placed  about  a 
ward  in  basins,  as  hand  lotions,  or  used  in  the  sputum-cups. 


4G4 


SURGICAL   BACTERIOLOGY,    ASEPSIS 


DISINFECTING  A  ROOM 

The  vapors  or  gases  of  certain  disinfectants  are  also 
used  for  purposes  of  disinfection,  more  especially  for  dwell- 
ings, furniture,  bedding,  and  clothing. 

Formaldehyd.— Of  all,  the  most  popular  germicide  at 
the  present  day  is  formaldehyd.  As  a  general  disinfectant 

_„,  for  a  sick-room  or  ward 
after  an  infectious  case 
it  is  unrivaled.  Several 
methods  are  used: 

1.  The  gas  may  be  lib- 
erated from  the  solution 
by  heat  in  a  special  ap- 
paratus designed  for  the 
purpose.  The  apparatus 
stands  outside  the  her- 
metically sealed  room,  and 


Fig. 


1 50. — Formaldehyd 
gator. 


fumi- 


Fig.  151.  —  Apparatus  for 
generating  formaldehyd  from 
tablets  of  polymerized  formal- 
dehyd: A  indicates  the  cup  in 
which  the  tablets  are  placed 
(Abbott). 


the  gas  is  introduced  through  a  fine  tube  which  fits  into 
the  keyhole  (Fig.  150). 

2.  Formaldehyd  tabloids  are  vaporized  by  being  heated 
on  a  metal  plate  over  a  special  lamp  designed  for  the 


DISINFECTING   A   ROOM  465 

purpose  (Schering's  lamp).  The  lamp  is  placed  inside 
the  closed  room.  To  prevent  risk  of  fire,  the  lamp  should 
be  placed  on  an  inverted  plate  or  tray,  in  a  basin  the  bot- 
tom of  which  contains  some  water. 

3.  A  simple  method  is  to  wring  sheets  out  of  a  solution 
of  formalin,  10  per  cent.,  and  hang  them  on  screens  or 
clothes'-lines  about  the  room,  which  is  then  hermetically 
closed. 

4.  Formaldehyd  may   be    liberated    by    combining    4 
ounces  of  formalin  (40  per  cent.)  with  1  ounce  perman- 
ganate  of    potash    crystals.      This  liberates  a  sufficient 
volume  of  gas  to  disinfect  a  space  of  1000  cubic  feet.     For 
each  additional  1000  cubic  feet  a  similar  quantity  is  added. 

A  pail  or  tub  large  enough  to  hold  at  least  5  gallons 
of  water  is  necessary,  as  the  combination  of  the  two 
ingredients  causes  the  mixture  to  boil  up  violently. 
Some  device  must  be  used  to  retain  the  heat  thus  gener- 
ated, without  which  the  gas  will  not  be  liberated. 
The  vessel  may  be  covered  with  asbestos,  or  old  blankets 
may  be  secured  round  it.  The  vessel  must  be  placed 
where  it  will  not  upset,  and  the  floor  round  should  be 
protected.  The  fumes  of  formaldehyd  are  exceedingly 
irritating.  If  it  is  absolutely  necessary  to  enter  a  room 
filled  with  formaldehyd,  the  gas  may  be  precipitated  by 
sprinkling  ammonia  water  freely  about  the  room. 

Sulphur. — Sulphur,  in  the  form  of  candles,  powder, 
or  rock  sulphur,  was  in  earlier  days  burnt  as  a  disinfectant 
for  rooms,  clothing,  and  furniture.  It  is  now  considered 
of  little  value  as  a  germicide.  It  has  one  valuable  prop- 
erty, however:  the  fumes  destroy  insect  life.  Sulphur 
fumigation  is  possibly  the  only  reliable  method  of  destroy- 
ing bedbugs. 

Five  pounds  of  sulphur  are  required  for  every  1000  feet 
of  cubic  space.  The  powdered  sulphur  is  heaped  in  an 
old  iron  plate  or  flat  basin,  which  should  be  raised  on  a 
couple  of  bricks  in  a  tub  or  wide  basin  containing  water, 
in  order  to  avoid  risk  of  fire.  The  tub  should  stand  on 
three  bricks  placed  evenly  on  the  floor.  The  sulphur  is 
wet  with  a  little  alcohol,  which  is  lighted  when  all  the 
preparations  are  made. 

30 


466  SURGICAL   BACTERIOLOGY,    ASEPSIS 

The  fumes  of  sulphur  will  discolor  metals  and  any  gild- 
ing on  decorations. 

Chlorin. — Chlorin  gas  may  be  liberated  in  the  following 
way,  and  is  sometimes  used  in  disinfecting  rooms : 

Mix  2  drams  of  common  salt  and  2  drams  of  black  oxid 
of  manganese;  place  in  a  saucer,  and  add  J  ounce  strong 
sulphuric  acid  diluted  one-third  with  water.  Enough 
chlorin  is  liberated  to  disinfect  a  space  of  32  square  feet 
(L.  L.  Dock). 

To  ascertain  the  number  of  cubic  feet  in  a  room,  multi- 
ply the  length  by  the  breadth,  and  the  result  so  obtained 
by  the  height.  For  example: 

Length       Breadth  Height 

20  feet  X   15  feet  =  300  feet  X  10  feet  =  3000  cubic  feet. 

In  preparing  a  room  for  disinfection  all  the  furniture 
is  arranged  so  that  every  part  is  exposed  to  the  fumes. 
Drawers  and  doors  of  closets  should  be  wide  open  and 
emptied  of  their  contents.  Clothing,  linen,  etc.,  should 
be  hung  about  the  room  on  screens  or  improvised  clothes- 
lines. The  window-shades  should  be  drawn  down.  All 
chinks  in  doors  or  windows  should  be  stuffed  with  tow, 
old  cloths,  or  pasted  over  with  strips  of  newspaper.  The 
radiator  must  be  closed,  and  if  there  is  an  open  chimney, 
it  must  also  by  some  means  be  stopped  up,  preferably 
with  a  closely  fitting  board. 

When  all  is  ready,  the  disinfectant  is  started,  and  the 
door  immediately  closed,  the  keyhole  and  door  chinks 
being  also  stuffed  up.  Nurses  have  been  known  to  use 
adhesive  plaster  for  this  purpose :  the  extravagance  of  such 
a  proceeding  has  only  to  be  pointed  out. 

The  room  is  left  closed  for  from  twelve  to  twenty-four 
hours,  after  which  fresh  air  and  sunlight  are  freely  admitted 
and  every  available  part  of  the  room  and  the  furniture 
thoroughly  cleaned  with  soap  and  water. 

DISINFECTION  OF  EXCRETA 

The  proper  disinfection  of  the  excreta  is  an  important 
part  of  a  nurse's  duties  in  those  infections  where  the  bac- 


DISINFECTION   OF   EXCRETA  467 

teria  of  the  disease  are  present  in  the  excreta,  as  in  typhoid 
fever,  cholera,  and  dysentery. 

Chemical  disinfection  is  attained  by  mixing  the  stool 
(or  urine,  sputum,  etc.)  thoroughly  with  a  strong,  anti- 
septic solution.  In  many  hospitals  bichlorid  of  mercury 
(1 : 1000)  or  carbolic  (1 :  20)  are  used.  We  saw,  however, 
that  these  were  not  perfect  disinfectants  for  organic  secre- 
tions, their  tendency  being  to  coagulate  the  albumin  and 
thus  arrest  the  action  of  the  disinfectant  on  the  bacteria 
inclosed  in  the  albuminous  capsule.  To  be  effective,  an 
equal  quantity  of  the  disinfectant  must  be  stirred  into  the 
stool  and  set  aside  for  several  hours  in  a  closed  vessel;  as 
a  rule,  this  is  not  practical.  Formalin  (2  to  4  per  cent.) 
is,  on  account  of  its  volatility,  also  not  an  ideal  disin- 
fectant for  the  purpose.  Chlorinated  lime  (10  per  cent.) 
is,  on  the  whole,  considered  the  best  chemical  disinfectant 
for  excreta.  An  equal  quantity  of  the  solution  should  be 
thoroughly  mixed  with  the  stool,  and  allowed  to  stand  fif- 
teen minutes  before  being  emptied  down  the  soil-pipe. 
The  vessel  should  be  covered  meanwhile  with  a  cloth 
wrung  out  of  bichlorid  of  mercury  (or  other  disinfectant). 

Boiling. — In  some  hospitals  a  special  hopper  in  which 
stools  and  urine  are  sterilized  by  boiling  is  used.  The  hop- 
per is  connected  with  a  steam  pipe;  some  water  is  mixed 
with  the  stool  in  the  hopper,  the  hopper  closed,  and  the 
steam  turned  on.  The  stool  is  allowed  to  boil,  usually 
for  five  minutes,  then  the  steam  is  turned  off,  the  valve 
connecting  the  hopper  with  the  soil-pipe  opened,  and  the 
hopper  flushed  as  in  an  ordinary  water-closet. 

In  country  districts  where  there  is  no  water  system  the 
stool  may  be  emptied  into  a  covered  pail  and  mixed  with  a 
generous  allowance  of  freshly  made  whitewash  or  with 
chlorinated  lime,  and  the  whole  buried  in  some  spot  away 
from  the  habitation  and  at  a  safe  distance  from  all  possible 
contamination  of  any  water-supply. 

The  vessel  which  has  contained  an  infectious  stool 
should  also  be  disinfected  immediately  after  use.  In 
modern  hospitals  medical  wards  are  usually  provided 
with  a  sterilizer  in  which  bed-pans,  urinals,  and  sputum- 
cups  can  be  sterilized  by  steam.  Where  this  is  not  the 


MEASURING    SOLUTIONS  469 

case,  they  may  be  kept,  after  being  cleaned,  soaking  in  a 
tank  filled  with  a  disinfectant,  usually  bichlorid  of  mercury 
(1:  1000)  or  formalin  (2  per  cent.). 

MEASURING   SOLUTIONS 

Disinfectants,  lotions,  etc.,  are  usually  sent  to  the  wards 
in  concentrated  solutions,  to  which  water  is  added  to  dilute 
them  to  the  required  strength.  Practice  is  necessary  to 
teach  nurses  to  reckon  the  percentages  accurately. 

Metric  System. — The  simplest  and  most  accurate 
method  is  to  employ  the  metric  system.  The  percentage 
is  then  easily  understood,  as  so  many  grams  (solid)  or 
cubic  centimeters  (fluid)  in  each  100  cubic  centimeters 
of  water.  To  find  the  total  amount  it  is  only  necessary 
to  multiply  the  percentage  by  the  number  of  hundred 
cubic  centimeters  required:  thus,  to  make  500  c.c.  of  a 
2  per  cent,  solution,  multiply  2  by  5,  and  we  find  we  shall 
want  10  c.c.  or  10  grams  of  the  drug.  Similarly,  1  in  20, 
500,  or  1000  signifies  one  gram  or  cubic  centimeter  in  each 
20,  500,  or  1000  c.c.  of  water. 

Apothecaries'  Measure. — In  using  the  apothecaries' 
measure  the  proportion  is  most  easily  found  by  using  the 
ounce  as  the  basis  of  measurement.  The  ounce  contains 
480  minims;  for  practical  purposes,  in  making  up  anti- 
septics in  the  large  bulk  in  which  they  are  used,  it  is 
usually  considered  sufficient  to  consider  the  ounce  as  a 
measure  of  500  minims.  The  amount  of  the  drug  re- 
quired in  each  ounce  is  then  readily  found  by  multiplying 
the  percentage  by  5. 

Thus:  1  per  cent,  requires  5  grains  or  minims  in  each 
ounce;  5  per  cent,  requires  25  grains  or  minims  in  each 
ounce;  10  per  cent,  requires  50  grains  or  minims  in  each 
ounce,  and  so  forth. 

Where  the  percentage  is  expressed  as  1  in  20,  25,  etc., 
one  part  of  the  drug  is  allowed  in  every  20,  25,  etc.,  of  the 
whole  quantity,  whether  minims,  drams,  ounces,  or  pints. 

Solutions  of  which  the  percentage  is  reckoned  in  thou- 
sands (1:  1000,  etc.)  may  be  prepared  by,  in  the  first  place, 
adding  to  each  ounce  (500  minims)  one  grain  or  one  minim 
of  the  drug.  We  have  then,  as  a  basis,  a  solution  of  the 


470  SURGICAL   BACTERIOLOGY,    ASEPSIS 

strength  of  1 :  500,  which  can  be  diluted  to  the  required 
strength  by  adding  sufficient  water. 

To  find  the  amount  of  water  to  be  added  to  a  solution 
of  known  percentage  in  order  to  make  a  solution  of  a 
weaker  strength,  divide  the  strength  required  by  the 
strength  of  the  original  solution  and  subtract  one  (i.  e., 
one  part)  from  the  answer. 

For  example,  to  make  1 :  3000  from  1 :  500—3000  •*•  500 
-6-1  =  5. 

The  division  shows  we  want  a  solution  one-sixth  the 
strength  of  the  original;  we  make  this  by  taking  five  parts 
water  and  one  part  of  our  original  solution. 

In  mixing  solutions  from  the  crude  drug,  warm,  not  hot, 
water  should  be  used,  except  for  carbolic  acid,  boric  acid, 
and  normal  salt  solution,  which  are  more  thoroughly  and 
quickly  dissolved  in  boiling  hot  water.  Cold  water  is 
used  in  making  solutions  of  alcohol,  formalin,  and  prepa- 
rations of  lime.  Cold  water  is  also  used  (5  per  cent.)  to 
liquefy  the  carbolic  crystals. 

The  bottles  used  should  be  sterile,  and  provided  with 
glass  stoppers  instead  of  the  ordinary  cork,  which  is  an 
absorbent  material. 

Before  pouring  a  solution,  nurses  should  be  taught  to 
wipe  the  rim  of  the  bottle  with  a  gauze  sponge  soaked  in 
a  little  of  the  solution  to  remove  any  dust  that  may 
adhere. 


CHAPTER  XIII 

PREPARATION    AND    STERILIZATION    IN    SUR- 
GICAL WORK 

The  Hands — Field  of  Operation — Instruments — Rubber  Vessels 
— Sutures  and  Ligatures:  Catgut,  Plain,  lodin,  Formalin,  Chrom- 
ieized,  Cumol — Dusting-powders — Oils  and  Ointments — Dressings 
— Sea-sponges — Brushes— Cultures. 

IN  carrying  the  principles  of  asepsis  into  practice  at 
an  operation  or  a  surgical  dressing,  we  have  two  points 
to  consider: 

1.  The  preliminary  preparation  of  all  things  to  be  used 
which  may  be  channels  of  infection. 

2.  The  methods  by  which,  at  an  operation  or  dressing, 
they  are  so  handled  as  to  insure  their  remaining  "sterile." 
The  object  of  either  is,  first  and  last,  the  prevention  of 
infection  or  bacterial  invasion  of  the  wound. 

Under  the  first  heading  we  must  consider  the  prepara- 
tion of  the  hands  of  the  operator  and  of  those  concerned 
in  assisting  him,  and  of  the  field  of  operation,  the  sterili- 
zation of  instruments,  ligatures,  sutures,  dressings,  and 
appliances. 

The  following  are  the  methods  accepted  at  the  present 
day  in  the  leading  American  hospitals,  and,  with  some 
modifications,  are  in  practically  universal  use. 

THE  HANDS 

The  most  important  part  of  any  preparation  involving 
the  skin  is  a  preliminary  scrubbing  with  hot  soap  and 
water,  using  a  small  scrub-brush  whenever  possible.  This 
is  especially  important  in  the  preparation  of  the  hands. 
In  operative  work  the  so-called  preparation  of  the  hands 
includes  always  the  forearms  to  a  point  above  the  elbow. 

Liquid  green  soap  or  tincture  of  green  soap  (an'  alcoholic 
preparation  of  green  soap)  is  usually  preferred;  it  can  be 
sterilized  and  kept  in  sterile  flasks.  A  hand-brush  and 

471 


472      PREPARATION,    STERILIZATION    IN   SURGICAL   WORK 

nail-cleaner,  sterilized  since  last  used,  should  be  provided 
for  each  person.  The  water  should  be  changed  at  least 
twice  during  the  process;  unless  the  water  in  the  pipes 
is  actually  sterile,  it  is  not  usually  practical  to  provide 
sterile  water  for  the  mechanical  part  of  the  preparation 
of  the  hands;  it  should,  however,  be  carefully  filtered. 

The  preliminary  scrubbing  should  be  invariably  carried 
out  by  the  clock,  ten  full  minutes  being  given.  Thus: 

1.  Wash  thoroughly  in  a  lather  of  soap  and  very  hot 
water  two  minutes;  rinse  in  running  water;  change  the 
water. 

2.  Clean  the  nails  and  remove  loose  epithelium  round 
the  nails  with  the  nail-cleaner.     (Any  one  actively  en- 
gaged in  surgical  work  should  keep  the  nails  very  short.) 

3.  Scrub  vigorously  with  the  brush  three  minutes,  pay- 
ing particular  attention  to  clean  thoroughly  between  the 
fingers;  rinse  in  running  water;  change  the  water. 

4.  Repeat   the   scrubbing   until   the   ten   minutes   are 
complete. 

The  preliminary  scrubbing  effectively  carried  out,  there 
are  two  or  three  methods  of  chemical  disinfection  in  general 
use.  The  solution  should  be  contained  in  sterile  basins 
of  sufficient  size  and  depth  to  allow  the  arms  to  be  im- 
mersed. 

Schatz  method,  also  known  in  America  as  the  Kelly 
method : 

1.  After  scrubbing  as  above,  immerse  in  a  saturated 
solution   of  potassium   permanganate   until   the   skin  is 
brown. 

2.  Immerse  in  a  saturated  solution  of  oxalic  acid  until 
the  color  is  removed. 

3.  Rinse  in  sterile  lime-water  to  neutralize  the  acid. 

4.  Immerse  in  bichlorid  of  mercury  1 :  1000  and  scrub 
the  skin  briskly  for  a  full  minute. 

A  modification  of  this  method,  omitting  the  lime-water 
bath,  is  in  common  use. 

Fiirbringer  Method. — 1.  After  scrubbing  as  above, 
immerse  in  pure  alcohol  (unheated)  for  one  minute,  rub- 
bing the  skin  briskly  to  remove  the  superficial  epithelium 
and  fat. 


THE   FIELD   OF  OPERATION  473 

2.  Repeat  the  process  in  bichlorid  of  mercury  (1 : 1000) 
for  three  minutes. 

Weir  or  Stimson  Method. — 1.  After  scrubbing  as  above, 
make  a  paste  of  equal  parts  of  chlorinated  lime  and  car- 
bonate of  soda,  with  cold  sterile  water.  Rub  the  paste 
into  the  skin  of  the  hands  and  forearms  for  five  minutes. 

2.  Rinse  in  sterile  water. 

3.  Wash  in  weak  solution  of  ammonia  water  to  neutral- 
ize the  odor  of  chlorin. 

Once  the  hands  have  been  sterilized,  care  must  be  taken 
that  they  come  in  contact  with  nothing  unsterile.  Nurses 
should  be  taught  to  hold  their  hands  after  " scrubbing  up" 
with  the  elbows  acutely  flexed  and  the  hands  on  a  level 
with  the  shoulder.  This  keeps  the  hands  out  of  the  way, 
and  the  position  is  a  reminder  of  the  care  to  be  exercised. 

THE  FIELD   OF  OPERATION 

On  account  of  the  irritation  to  the  tissues  the  field  of 
operation  is  not  prepared  more  than  about  twelve  hours 
before  the  operation.  Many  surgeons  at  the  present  day 
prefer  no  preparation  other  than  washing  with  soap  and 
water,  until  the  patient  is  on  the  table. 

In  preparing  the  field,  a  wide  area  is  scrubbed  with 
soap  (tincture  of  green  soap  usually)  and  hot  sterile  water, 
using,  wherever  possible,  a  hand  scrub-brush,  and  shaved 
with  a  sharp  razor  and  a  good  lather.  At  least  five  min- 
utes should  be  given  to  the  scrubbing.  The  scrubbing 
over,  the  soap  is  removed  with  hot  water  and  the  area 
washed  with  alcohol  and  then  ether,  in  order  to  remove 
all  grease  and  debris  of  superficial  epithelium,  and  to  pre- 
pare the  way  for  the  disinfectant.  Finally,  the  surface 
is  freely  flushed  with  a  hot  solution  of  bichlorid  of  mer- 
cury, 1 : 2000. 

Nurses  should  be  taught  to  use  sponges  for  the  alcohol 
and  ether  washings  and  not  to  flush  the  area  from  the 
flasks,  a  practice  that  is  quite  unnecessary  and  very  ex- 
travagant. 

The  area  is  then  covered  either  with  dry  sterile  towels 
or  with  towels  wrung  out  of  the  hot  bichlorid  solution 


474      PREPARATION,    STERILIZATION   IN   SURGICAL    WORK 

and  covered  with  a  piece  of  thin  rubber  sheeting.  This 
dressing  is  secured  by  bandages  and  safety-pins  and  is 
not  removed  until  the  patient  is  on  the  table. 

In  those  cases  of  abdominal  section  where  there  is  local 
tenderness  or  distention,  preparation  of  the  area  is  usually 
postponed  until  the  patient  is  under  the  anesthetic.  If 
it  is  carried  out,  it  must  be  done  with  extreme  gentleness, 
using  sponges  only  and  no  brush. 

Some  gynecologists  use  Kelly's  process  of  skin  prepara- 
tion for  abdominal  sections,  using  sponges  in  place  of  the 
immersion.  Great  care  must  be  taken  that  the  oxalic 
acid  is  completely  removed,  and  that  none  is  allowed  to 
escape  and  run  down  the  patient's  back,  where  it  will  irri- 
tate and  possibly  burn  the  skin. 

The  skin  preparation  should  be  carried  out  with  the 
same  care  in  preparing  an  area  for  minor  operations,  such 
as  exploration,  aspiration,  hypodermoclysis,  etc. 

A  minimum  preparation  is  permitted  in  giving  hypo- 
dermic injection  of  medicines.  Provided  that  all  that  is 
to  be  used  is  sterile,  it  is  considered  sufficient  to  wash  a 
small  local  area  with  alcohol  (p.  356).  The  puncture  is 
so  fine  that  it  practically  closes  as  soon  as  the  needle  is 
withdrawn. 

In  preparing  the  field  of  operation,  the  preparation 
should  also  include  a  generous  portion  of  the  surface  in 
the  vicinity  of  the  proposed  incision.  In  determining 
the  area  to  be  prepared  for  various  operations  the  follow- 
ing list  is  compiled  from  the  instructions  issued  to  the 
nursing  staff  of  Johns  Hopkins  Hospital,  The  Pennsylvania 
Hospital,  Philadelphia,  and  the  Philadelphia  Polyclinic 
Hospital. 

Abdominal  Cases. — From  the  nipple  to  the  knee,  and 
from  the  bed-line  on  either  side.  Shave  the  pubesand 
the  abdominal  wall  from  the  umbilicus  four  inches  on 
either  side  the  median  line. 

Stomach. — From  the  clavicle  to  the  pubes,  and  from 
the  bed-line  on  either  side. 

Kidney. — From  sternum  to  spine  on  the  affected  side, 
and  from  axilla  to  hip. 

Breast. — From  the  hair-line  and  ear  to  the  waist-line; 


THE   FIELD   OF   OPERATION  475 

from  the  nipple  on  the  opposite  side  to  behind  the  shoulder 
of  the  affected  side;  the  arm  to  the  elbow  and  the  axilla  of 
the  affected  side,  shaving  the  axilla. 

Glands  of  Axilla.- — From  the  sternum  to  the  spine  on 
the  affected  side,  and  from  neck  to  waist;  the  arm  to  the 
elbow,  shaving  the  axilla. 

Glands  of  Neck. — Hair-line  (above,  if  the  glands  are 
high)  to  nipple;  axilla  and  shoulder  on  affected  side, 
shaving  the  axilla;  the  arm  to  the  elbow. 

Brain. — Shave  the  whole  head,  prepare  the  skin  of  the 
head  and  neck. 

Limbs. — Shave  and  prepare  well  above  and  below  the 
affected  part. 

Nurses  may  have  to  be  warned  against  shaving  where 
it  is  unnecessary.  A  razor  should  never  be  used  on  the 
face,  neck,  breast,  or  arm  (except  the  axilla)  of  a  woman 
without  distinct  orders.  When  an  area  has  been  shaved, 
the  hair  is  always  apt  to  grow  in  again  more  strongly, 
which  may  be  disfiguring.  An  eyebrow  is  also  not  to  be 
removed  without  definite  instructions. 

Vagina  and  Cervix. — Place  the  patient  in  the  lithotomy 
position.  Shave  the  labia  and  lower  half  of  pubes;  pre- 
pare the  external  genitals,  covering  the  area  from  the  pubes 
to  the  bed-line;  continue  the  preparation  to  the  inner  sur- 
face of  the  thighs  and  buttocks,  about  eight  inches  on 
either  side.  Cover  the  genitals  with  a  large  sterile  perineal 
pad  applied  with  a  T-bandage. 

A  hot  antiseptic  douche  (bichlorid  of  mercury  1 : 5000, 
boric  acid,  2  per  cent.,  or  lysol,  2  per  cent,  is  frequently 
ordered  as  part  of  the  preparation. 

Some  gynecologists  order  the  vagina  washed  with  soap 
and  hot  water  before  the  douche.  The  patient  lies  in  the 
lithotomy  position,  the  vagina  held  open  with  a  Sims 
speculum;  the  cleansing  is  done  with  gauze  sponges  on 
long  sponge-holders.  This  preparation  is  usually  post- 
poned until  the  patient  is  under  ether. 

The  Rectum. — Shave  in  the  vicinity  of  the  anus,  and 
prepare  the  buttocks  and  inner  surface  of  thighs  about 
eight  inches  on  either  side  and  to  the  bed-line  (lithotomy 
position).  Cleanse  the  rectum  by  enemata  of  hot  soap 


470      PREPARATION,    STERILIZATION    IN   SURGICAL    WORK 

and  water,  repeated  until  the  lower  bowel  is  entirely 
empty.  No  dressing  is  applied. 

An  irrigation  (usually  creolin,  2  per  cent.)  an  hour  before 
the  operation  may  be  ordered,  and  in  particular  cases  a 
medicated  suppository  may  be  necessary.  This  is  a  spe- 
cial order,  and  not  part  of  the  routine  treatment. 

The  Mouth,  Tongue,  Palate,  etc. — For  some  days  pre- 
viously an  antiseptic  mouth-wash  is  used  two  or  three 
times  a  day.  Usually  peroxid  of  hydrogen,  diluted  with 
equal  parts  of  lime-water,  is  the  wash  preferred.  For 
major  operations  the  mustache  and  beard  are  shaved. 
The  teeth  are  previously  put  in  order  by  a  dentist. 

The  Nose. — For  an  operation  of  any  extent  on  the  nose 
the  mustache  is  shaved  and  the  face  from  hair-line  to  chin 
prepared  in  the  usual  way.  A  preliminary  nasal  douche 
of  warm  boric  solution  (2  per  cent.)  or  other  antiseptic  may 
be  ordered. 

The  Ear. — For  minor  operations  on  the  auditory  canal 
or  the  ear-drum  cleanse  the  external  ear  and  the  auditory 
meatus,  using  for  the  latter  small  pledgets  of  cotton. 
Leave  a  pledget  soaked  in  the  antiseptic  in  the  meatus. 
For  mastoid  operations  shave  and  prepare  half  the  head, 
and  prepare  face,  neck,  and  upper  half  of  shoulder  on  the 
side  of  the  affected  ear.  Douching  is  not  usually  ordered. 

The  Eyes.— 1.  Wash  the  face  from  hair-line  to  lips  with 
soap  and  water,  and  sponge  with  alcohol,  taking  care  to 
keep  the  eyelids  closed. 

2.  Hold  the  conjunctivalsac  well  open  and  douche  thor- 
oughly with  warm  boric  solution  (2  per  cent.)  or  with 
bichlorid  of  mercury  1: 10,000;  boric  is  usually  preferred, 
as  mercury  produces  a  dry,  uncomfortable  sensation.     No 
force  must  be  used. 

3.  Cover  the  affected  eye  with  a  sterile  gauze  pad,  and 
over  that  place  a  gauze  dressing  to  cover  the  face  on  the 
affected  side. 

The  preparation  is  usually  ordered  about  one  hour 
before  the  operation. 

Eye  drops  of  atropin  are  frequently  ordered  as  part  of 
the  preparation.  (See  Chapter  IV.)  They  will,  however, 
be  introduced  at  a  specified  time,  and  not  necessarily  at 


THE   FIELD   OF   OPERATION  477 

the  time  of  the  skin  preparation.  If  both  eyes  are  ordered 
to  be  prepared,  or  if  neither  is  covered,  the  eye  to  be  op- 
erated on  should  be  indicated  by  some  intelligible  mark. 
One  accident  is  on  record  where  the  wrong  eye  was  re- 
moved, resulting  in  total  blindness. 

Skin-grafting. — In  the  preparation  of  a  wound  to  be 
grafted  (i.  e.,  to  be  covered  over  with  living  tissue)  anti- 
septics are  avoided,  as  they  coagulate  the  albumin  and  to 
some  extent  destroy  the  vitality  of  the  tissues. 

The  wound  is  usually  cleansed  with  normal  salt  solu- 
tion and  covered  with  a  wet  dressing  of  the  same. 

The  area  from  which  the  grafts  are  to  be  taken  is  pre- 
pared according  to  the  usual  formula,  followed  by  a  thor- 
ough washing  with  normal  salt  solution,  and  covered 
simply  with  a  dry,  sterile  towel.  After  the  preparation 
no  antiseptics  are  used  either  in  covering  the  area  or  dur- 
ing the  operation.  Many  surgeons,  indeed,  omit  the  anti- 
septics also  from  the  preliminary  preparation,  and  order 
only  a  thorough  cleansing  with  soap  and  water  and  flush- 
ing with  normal  salt  solution. 

The  grafts  are  usually  taken  from  the  inner  surface  of 
the  thigh.  The  whole  of  the  inner  surface  is  prepared. 

Cauterization;  Wet-cupping. — In  preparing  the  skin 
for  cauterization  by  the  actual  cautery  or  for  wet-cupping 
neither  alcohol  nor  ether  is  generally  used,  the  reason 
being  that,  unless  completely  removed  from  all  parts, 
such  inflammable  substances  may  readily  ignite  and 
cause  a  burn.  The  preparation  is  done  immediately 
before  the  application. 

Dirty  and  Infected  Wounds. — The  preparation  of  such 
depends  on  the  extent  and  nature  of  the  injury,  and  no 
special  rules  can  be  laid  down.  When  possible,  they  are 
usually  washed  with  soap  and  water  and  irrigated  with 
an  antiseptic.  The  area  round  the  wound  should  first 
be  cleansed,  washing  away  from  the  wound;  where  neces- 
sary, as  in  scalp  injuries,  it  must  also  be  shaved.  After 
cleansing  and  disinfecting,  a  wet  antiseptic  dressing  is 
usually  applied. 


478      PREPARATION,   STERILIZATION  IN   SURGICAL   WORK 

INSTRUMENTS 

Instruments,  except  those  with  cutting-edges,  are  ster- 
ilized by  boiling  for  ten  minutes.  To  prevent  spotting 
with  rust,  the  water  should  be  actively  boiling  at  the  time 
of  immersion,  and  should  completely  cover  the  instru- 
ments. Bicarbonate  of  soda,  1  per  cent,  (about  three  level 
teaspoons  to  the  quart),  is  frequently  added  to  the  water, 
also  for  the  prevention  of  rust,  but  must  be  omitted  if 
rubber  or  silk  materials  are  boiled  at  the  same  time. 
Shot  and  safety-pins  are  boiled  with  the  instruments — 
the  shot  in  small  muslin  bags,  the  safety-pins,  for  con- 
venience, strung  six  at  a  time  on  a  safety-pin. 

In  hospital  work  the  instrument  sterilizer  is  a  wide 
metal  boiler  filled  with  one  or  more  trays  on  which  the 
instruments  are  placed  for  sterilization,  and  on  which 
they  can  be  removed  and  carried  to  the  operating-table 
without  handling.  In  private  work  a  fish-kettle  makes 
an  excellent  substitute. 

After  use,  instruments  should  at  once  be  covered  with 
cold  water  until  ready  to  be  cleaned;  this  is  in  order  to 
dissolve  the  albumin  in  the  blood-stains. 

In  cleaning,  the  steps  are  as  follows: 

1.  Remove  the  blood-stains  with  cold  water. 

2.  Place  in  boiling  water  and  boil  for  ten  minutes. 

3.  Scrub  with  hot  water  and  Sapolio,   Bon  Ami,   or 
similar  soap. 

4.  Drain  on  a  towel,  dry  thoroughly,  rub  up  with  a 
little  alcohol. 

Whiting,  made  into  a  paste  with  alcohol  and  ammonia, 
is  sometimes  used  to  polish  plated  instruments.  Ex- 
treme care  is  then  necessary  to  remove  all  traces  of 
powder  from  joints  and  teeth.  In  many  hospitals  the 
use  of  paste  is  forbidden. 

Scissors,  forceps,  needle-holders,  and  all  shutting  instru- 
ments should  be  open  while  being  sterilized,  and  should 
be  kept  open  while  in  the  instrument  closet,  in  order  not 
to  strain  the  spring  unnecessarily.  During  operations 
it  is,  however,  a  convenience  to  string  artery  forceps 
(closed)  together,  six  at  a  time  on  a  safety-pin.  This  is 


INSTRUMENTS  479 

generally  allowed,  provided  they  have  previously  been 
sterilized  open  since  the  last  operation. 

Sharp  Instruments. — Boiling  to  a  great  extent  blunts 
sharp  instruments,  such  as  knives,  needles,  scissors,  etc. 
The  rule  usually  is  that  instruments  with  flat  surface  and 
without  grooves  or  joints,  such  as  knives  and  needles, 
are,  after  use,  boiled  for  three  minutes  in  actively  boiling 
water.  Before  an  operation  they  are  immersed  in  boil- 
ing water  for  one  minute  half  an  hour  before  the  time 
fixed,  and  placed  directly  in  pure  alcohol  until  required. 
Scissors  and  curettes  are  boiled  five  minutes  after,  and 
three  minutes  before,  use;  they  also  may  be  placed  in 
alcohol,  but  this  is  not  usually  considered  necessary. 

Cutting  instruments  are  protected  during  boiling  and 
when  not  in  use  by  winding  the  blades  with  a  fine  strand 
of  cotton;  they  should  always  be  boiled  separately  from 
other  instruments.  Needles  may  be  run  through  a  piece 
of  gauze  for  convenient  handling;  when  not  in  use,  they 
may  be  kept  in  covered  glass  boxes  with  a  little  emery 
powder  to  prevent  rusting,  or  they  may,  after  sterilization, 
be  put  up  in  pairs  between  two  folds  of  gauze,  and  a  con- 
venient number  kept  thus  ready  for  immediate  use  in 
sterile,  covered  glass  jars.  Each  jar  should  contain  needles 
of  only  one  variety. 

The  points  and  blades  of  cutting  instruments  should 
always  be  tested  after  use,  since  a  blunt  instrument 
inflicts  needless  injury  on  the  tissues.  A  piece  of  fine  kid 
or  chamois  leather  is  used;  if  the  knife  is  sharp,  the  slight- 
est downward  cutting  movement  will  make  a  sharp  cut. 
Spots  and  rust-marks  are  removed  from  needles  and 
blades  with  emery  powder.  A  small  board  covered  with 
flannel  is  kept  for  the  purpose;  the  instrument  is  laid  flat 
on  the  board  and  covered  with  emery  powder,  and  rubbed. 

Needles. — The  different  needles,  and  the  purposes  for 
which  the  varieties  are  used,  should  be  taught  the  pupils 
in  a  demonstration  class.  For  the  skin  and  connective 
tissue,  which  are  tough,  resistant  tissues,  needles  with 
cutting  blades  are  used;  for  tissues  that  are  easily  torn  and 
vascular,  such  as  the  kidney,  intestines,  cervix,  etc., 
rounded  needles,  the  point  only  sharp,  more  like  the  ordi- 


480      PREPARATION,   STERILIZATION   IN   SURGICAL   WORK 

nary  sewing-needle,  are  preferred;  needles  with  flat  blunt 
blades,  the  point  only  sharp,  are  used  for  suturing  deep 
fascia  without  injury  to  the  adjacent  tissues;  needles  for 
superficial  work  are  usually  straight  or  semi-curved; 
those  used  for  the  deeper  fascia  are  curved.  Needles  for 
the  deeper  facsia  are  mounted  on  holders,  of  which  there 
are  a  large  variety,  almost  every  surgeon  having  some 
special  preference  in  this  respect.  According  to  conve- 
nience, the  eye  of  the  needle  may  be  at  the  blunt  end  or 
at  the  point.  For  the  deeper  fascia,  where  a  holder  is 
necessary,  the  eye  is  more  frequently  at  the  point.  A  few 
needles  for  special  purposes  are  frequently  made  with  their 
own  handles;  such  are  the  needles  used  in  operations  for 
hernia  (right  and  left),  for  cleft-palate,  and  for  suturing 
the  pedicle  or  stump  in  operations  for  removing  the  ova- 
ries. An  aneurysm  needle  is  also  mounted  on  its  own  han- 
dle; it  is  a  flat,  blunt,  semi-curved  blade,  the  eye  at  the 
point,  used  in  transfixing  blood-vessels,  as,  for  example, 
in  the  simple  operation  of  intravenous  infusion.  The 
needles  are,  as  a  rule,  in  charge  of  the  nurse  at  an  opera- 
tion. 

Hollow  needles,  such  as  those  used  for  hypodermic 
injection,  exploration,  aspiration,  intravenous  infusion, 
etc.,  require  special  care  in  cleaning  and  sterilizing  to  pre- 
vent the  fine  tube  becoming  clogged  with  rust  or  with 
coagulated  albumin. 

Invariably,  immediately  after  use,  they  must  be  washed  in 
cold  water,  which  must  run  freely  through  the  needle.  If 
attached  to  a  syringe,  the  water  is  drawn  and  expelled 
repeatedly  through  the  needle.  The  wire  must  be  passed 
through  the  needle  repeatedly  during  the  process,  to  help 
in  the  removal  of  any  deposit.  When  clean,  the  wire  is 
inserted  and  the  needle  boiled  three  minutes.  Before 
putting  away,  the  needle  must  be  dried  by  briskly  moving 
the  wire  in  and  out,  drying  it  each  time.  When  perfectly 
dry,  the  wire  is  inserted  and  kept  in  place.  The  wire 
must  come  well  beyond  the  point  of  the  needle,  in  order 
to  protect  it.  In  sterilizing  before  use  the  needle  is  boiled 
one  minute  with  the  wire  in  place;  the  wire  is  then  with- 
drawn, the  needle  attached  to  the  syringe,  and  alcohol 


INSTRUMENTS  481 

drawn  and  expelled  at  least  ten  times  through  the  needle, 
and  kept  in  the  alcohol  until  required.  Needles  not 
attached  to  a  syringe  are,  after  boiling  one  minute, 
immersed  in  alcohol  half  an  hour  before  use  with  the  wire 
withdrawn.  The  hypodermic  needles  in  constant  use 
in  the  wards  are  conveniently  kept  in  covered  glass  boxes 
with  a  little  emery  powder  or  fine  shot,  which  keeps  them 
free  of  rust. 

Trocars  and  Cannulas.— Cannulas  are  cleaned  with  the 
same  special  care  as  hollow  needles,  but  may  be  boiled 
for  the  full  time,  like  non-cutting  instruments.  The 
trocar,  being  a  sharp  instrument,  is  sterilized  according 
to  the  formula,  the  point  being  protected  with  cotton. 
Trocars  and  cannulas  should  be  sterilized  separately;  a 
flexible  probe  is  used  in  place  of  the  trocar,  to  clean  the 
inside  of  the  cannula. 

Silver  catheters  must  also  be  cleaned  with  minute  care 
under  running  cold  water  immediately  after  use.  The 
stilette  is  used  like  the  wires  of  needles  to  clean  and  dry 
the  inside,  and  is  kept  in  place  while  the  catheter  is  not 
in  use,  but  is  removed  during  boiling.  Not  being  sharp 
instruments,  catheters  are  sterilized  by  boiling  the  full 
time.  No  paste  or  powder  should  be  permitted  in  clean- 
ing catheters,  as  it  is  difficult  to  prevent  it  lodging  in  the 
eye.  Scrubbing  with  hot  water  and  Sapolio,  followed  by 
rubbing  with  a  dry  chamois  leather,  is  sufficient  to  keep 
them  bright. 

Paquelin  Cautery. — An  instrument  requiring  a  special 
process  in  sterilizing  is  the  Paquelin  cautery.  The  tips, 
which  must  be  sterile,  are  made  of  hollow  platinum  (p.  147) 
and  are  readily  indented  when  heated.  After  use,  the 
tips  should  immediately  be  brought  to  white  heat  for  one 
minute,  in  order  to  burn  off  any  organic  matter  that  may 
be  adherent;  they  must  then  be  allowed  to  cool  slowly, 
in  such  a  position  that  they  will  not  be  exposed  to  knocks 
or  falls  while  soft.  When  thoroughly  cooled,  they  may 
be  washed,  if  necessary;  usually  rubbing  with  chamois 
leather  is  all  that  is  required.  The  heating  is  adequate 
sterilization.  The  same  process  is  used  in  sterilizing  the 
platinum  wires  used  in  taking  cultures. 

31 


482      PREPARATION,    STERILIZATION    IN   SURGICAL   WORK 

The  closet  in  which  instruments  are  stored  should  be 
dust  proof.  Those  made  of  glass  with  a  metal  frame  are 
the  most  easily  kept  clean.  To  prevent  rust,  a  dish  con- 
taining plaster-of-Paris,  which  absorbs  moisture  from  the 
atmosphere,  should  be  kept  in  the  closet  and  renewed  from 
time  to  time.  The  instrument  cases  made  by  the  leading 
firms  are  provided  with  a  barometer,  so  that  the  humidity 
of  the  air  in  the  case  can  be  gaged.  For  the  same  reason 
the  closet  should  be  in  as  dry  a  place  as  possible.  It 
should  not,  for  example,  be  exposed  to  steam  from  hot- 
water  supply  or  the  sterilizers. 

Nurses  should  be  taught  to  arrange  the  instruments  in 
convenient  groups,  and  invariably  in  the  same  order. 

Syringes. — Glass  syringes  with  a  glass  piston  or  with 
asbestos  packing  can  be  sterilized  by  boiling.  The  water 
must  be  cool  when  the  syringe  is  first  put  into  it  or  the 
glass  will  crack.  With  metal  attachments  and  rubber 
washers  boiling  is  impracticable.  The  syringe  is  then 
cleaned  by  drawing  first  cold  water  and  then  hot  soap  and 
water  in  and  out  of  the  syringe  repeatedly,  finally  rinsing 
thoroughly.  It  is  sterilized  by  drawing  formalin  (2  per 
cent.)  or  other  disinfectant  into  the  barrel  and  then 
placing  the  syringe  in  the  antiseptic  for  half  an  hour, 
taking  care  that  it  is  completely  covered.1  This  is  neces- 
sary if  the  syringe  is  to  be  used  for  exploratory  purposes 
or  for  the  administration  of  antitoxin  serum.  For 
ordinary  use  it  is  not  necessary  that  the  outside  of  the 
syringe  should  be  sterile.  If  the  washers  have  ^shrunk, 
they  must  be  soaked  in  sterile  water  to  swell  them  again. 

The  air-pump  attached  to  an  aspirating  apparatus  is 
sometimes  mistaken  for  a  syringe  and  ruined  by  having 
water  drawn  into  the  barrel.  The  air-pump  cannot  be 
thoroughly  sterilized  without  spoiling  it;  for  this  reason 
when  aspiration  is  performed  the  pump  is  worked  by  an 
"unsterile"  assistant.  (See  Chapter  XIV.) 

1  If  the  syringe  is  to  be  used  for  exploratory  purposes  or  for 
antitoxin  serum  injections,  alcohol  is  preferred  to  an  antiseptic. 


RUBBER  483 

RUBBER 

Prolonged  exposure  to  heat  destroys  rubber;  acids  cor- 
rode it;  if  in  contact  with  oil  or  grease,  it  becomes  soft  and 
partially  dissolved;  soap,  on  account  of  the  grease,  has 
also  a  deteriorating  effect;  while  all  rubber,  if  put  aside, 
readily  becomes  dry  and  cracked.  Rubber  appliances, 
therefore,  are  extremely  difficult  to  care  for,  and  are,  in 
addition,  expensive  items.  Some  general  rules  for  their 
care  are  applicable  to  all  rubber  articles. 

Do  not  use  soap  where  it  can  be  avoided;  in  scrubbing, 
use  tepid  water  in  place  of  hot,  remove  the  soap  quickly, 
and  rinse  very  thoroughly. 

Clean  in  cold  water  immediately  after  use  if  the  articles 
have  come  in  contact  with  organic  matter.  If  boiling  is 
necessary,  allow  three  minutes  for  thin  articles,  such  as 
gloves,  nipples,  and  fine  catheters  or  bougies,  and  five  for 
heavier  articles.  No  carbonate  of  soda  should  be  used, 
and  the  water  must  be  actively  boiling.  Protect  from 
contact  with  the  metal  of  the  sterilizer  by  laying  the 
articles  on  a  folded  towel.  Keep  light  rubber  articles 
(nipples,  gloves,  etc.)  from  floating  by  folding  in  a  towel 
or  by  tying  loosely  in  a  square  of  gauze  and  clipping  to 
the  little  package  a  pair  of  artery  forceps  to  act  as  a 
weight. 

Each  surface  of  the  article  to  be  cleaned  or  sterilized 
must  be  equally  thoroughly  cared  for.  Gloves  and  nipples 
must  be  turned  inside  out,  and  cleaned  on  either  side. 
Tubing  and  catheters  must  have  the  water  or  solution 
run  freely  through  them ;  this  is  most  thoroughly  done  by 
attaching  a  funnel  or  the  barrel  of  a  glass  syringe  to  one 
end,  and  holding  under  a  spigot  of  running  water. 

Hard-rubber  articles  (catheters,  nozzles,  tracheotomy 
tubes,  etc.)  are  temporarily  softened  by  exposure  to  heat 
and  lose  their  shape.  To  avoid  this,  if  boiling  is  neces- 
sary, insert  the  stilette  or  a  probe  bent  to  the  shape  and 
keep  it  in  place  during  boiling,  and  until  the  rubber 
hardens  again  on  cooling. 

Where  chemical  sterilization  is  preferred,  immersion  must 
bo  complete,  and  should  be  continued  for  a  specified  time, 
and  no  more.  At  the  present  day  formalin  (2  per  cent.) 


484      PREPARATION,    STERILIZATION    IN    SURGICAL   WORK 

is  a  favorite  disinfectant  for  this  purpose,  as  being  less 
destructive  than  other  antiseptics  and  quicker  in  its  action; 
thirty  minutes'  immersion  is  considered  sufficient  to 
destroy  bacteria.  After  immersion  rinse  thoroughly  in 
cold  sterile  water. 

Dry  all  rubber  goods  thoroughly  before  putting  away, 
and  keep  in  as  cool  a  place  as  possible.  In  drying  tubing, 
catheters,  etc.,  stretch  repeatedly  to  squeeze  all  moisture 
from  the  inside;  dry  gloves  and  nipples,  etc.,  on  both  sides. 
In  putting  away,  avoid  all  folding.  Keep  double  surfaces 
apart,  either  by  inflation  (air-cushions  and  beds,  etc.)  or  by 
keeping  gauze  or  cotton  between.  An  ice-bag,  for  exam- 
ple, not  in  use  should  be  kept  blown  up  and  lightly  packed 
with  gauze.  If  the  articles  are  out  of  use  for  any  length 
of  time,  they  should,  when  practical,  be  soaked  from  time 
to  time  in  cold  water. 

Gloves  of  thin,  flexible  rubber  are  at  the  present  day 
used  during  operations  and  for  other  surgical  proceedings, 
such  as  dressings,  and  vaginal  or  rectal  examinations,  as 
they  can  be  made  more  certainly  sterile,  and  are  more 
easily  kept  so,  than  the  hands.  Unless  quite  intact,  they 
may  be  a  source  of  danger,  since  they  cause  the  hands  to 
sweat  and  the  sweat  will  readily  ooze  through  any  small 
opening. 

Pricks  and  cuts  are  detected  by  holding  the  glove  in  a 
basin  of  water;  as  it  fills  under  water,  little  air-bubbles  will 
appear  at  any  puncture,  however  minute.  The  punctures 
must  be  sought  for  and  repaired  with  rubber  cement  after 
each  use.  Mended  gloves  can  be  used  by  the  nurses  or 
for  ward  dressings,  but  are  not  safe  for  operation,  on 
account  of  the  risk  of  the  small  patch  becoming  separated. 

After  use,  blood-stains  and  all  organic  matter  should 
be  removed  with  cold  water  while  still  wet,  after  which  each 
glove  is  scrubbed  inside  and  out  with  tepid  soapsuds, 
using  a  brush  thoroughly,  but  lightly,  and  rinsed  well  in 
cold  water.  New  gloves  are  treated  the  same  way  before 
use. 

In  sterilizing,  most  hospitals  use  the  autoclave,  espe- 
cially for  gloves  that  are  to  be  used  in  operating.  After 
cleaning,  dry  thoroughly,  powder  both  surfaces  freely  with 


RUBBER  485 

talcum  powder,  wrap  in  the  usual  double  cotton  covers, 
and  sterilize  with  the  dressings  twenty  minutes  at  fifteen 
pounds'  pressure.  In  other  hospitals  gloves  are  sterilized 
by  boiling  three  minutes  after  use  and  again  three  minutes 
before  use,  and  have  no  other  treatment  beyond  thorough 
cleaning. 

For  chemical  sterilization  clean  as  described,  then  im- 
merse completely  for  thirty  minutes  in  2  per  cent,  form- 
alin, rinse  in  sterile  cold  water,  dry  and  powder,  and  keep 
carefully  covered  from  dust.  Before  use  immerse  again 
in  the  solution  for  thirty  minutes. 

As  smooth  rubber  presents  an  almost  non-absorbable 
surface,  provided  the  cleansing  is  thorough,  the  articles  are 
readily  made  sterile. 

Gloves  are  less  liable  to  tear  and  more  easily  adjusted 
if  put  on  wet  and  inflated  either  with  sterile  water  or  anti- 
septic solution. 

Rubber  Tissue. — Sterile  rubber  tissue  is  frequently 
used  as  a  dressing  to  cover  granulating  surfaces.  It  pro- 
tects delicate  granulations  from  being  torn,  which  is  liable 
to  happen  when  dressings  that  have  stuck  to  the  tissues  are 
removed. 

To  prepare:  Scrub  lightly  in  tepid  soap  and  water  and 
rinse  in  cold  water.  Place  over  the  tissue  a  layer  of  gauze 
the  same  size  and  cut  both  together  to  the  required  shape 
and  size. 

Pack  in  sterile  jars,  a  layer  of  gauze  between  each  piece 
of  tissue. 

Fill  the  jars  with  bichlorid  of  mercury  1:  1000,  and  leave 
for  twenty-four  hours. 

Pour  off  and  refill  either  with  fresh  solution  of  the  same 
or  sterile  normal  salt  solution.  The  latter  is  usually 
preferred,  especially  if  the  tissue  is  to  be  used  for  skin- 
grafting  or  extensive  granulating  wounds. 

Rubber  tissue  should  be  tested  before  using,  as  it  is 
liable  to  become  brittle.  In  good  condition  it  is  pliable 
and  slightly  elastic.  The  tissue  is  dissolved  by  heat,  ether, 
chloroform,  turpentine,  and  similar  preparations. 

Rubber  Catheters,  Rectal  Tubes,  Etc. — The  cleansing 
and  sterilization  of  these  articles,  and  more  especially  of 


486      PREPARATION,   STERILIZATION   IN   SURGICAL  WORK 

catheters,  is  so  important  that  a  special  formula  should 
be  insisted  on  in  caring  for  them. 

Immediately  after  use,  wash  under  running  cold 
water,  using  a  funnel,  as  described,  two  minutes  by  the 
clock;  leave  soaking  in  cold  water  at  least  three  minutes 
longer. 

Scrub  in  tepid  water  and  suds;  rinse  under  running  cold 
water. 

Run  formalin  (2  per  cent.)  through  the  catheter  repeat- 
edly (at  least  ten  times),  and  soak  in  the  same  thirty 
minutes;  rinse  again  under  running  cold  water.  Boil 
three  minutes. 

Stretch  repeatedly  between  the  fingers  until  dry,  and 
put  away  dry. 

Repeat  the  boiling  immediately  before  use,  and  wrap 
in  a  sterile  towel  until  required,  or,  if  preferred,  place  in 
a  2  per  cent,  boric  acid  solution. 

The  formula  may  be  applied  to  rectal  tubes,  stomach- 
tubes,  and  rubber  tubing  used  for  drainage  if  required  to 
be  used  again.  Rectal  tubes  used  for  oil  enemata  quickly 
deteriorate,  as  it  is  practically  impossible  wholly  to  remove 
the  oil  from  the  inside.  They  should  be  kept  by  them- 
selves, as  other  rubber  articles,  if  put  with  them,  are  also 
spoiled  by  the  oil. 

In  most  hospitals  it  is  a  rule  that  new  rubber  tubing, 
catheters,  etc.,  are  thoroughly  washed  as  above,  and 
boiled  for  ten  minutes  once  as  a  preliminary  precaution. 

Catheters  of  Glass  or  Metal. — These  are  sterilized  by 
boiling,  usually  ten  minutes  after  use  and  cleaning,  and 
five  minutes  before  use,  are  required.  As  they  can  be 
sterilized  with  certainty,  glass  catheters  are  used  wherever 
practical  in  preference  to  rubber  ones. 

The  finest  (filiform)  catheters  and  bougies  of  hard 
rubber  or  of  silk  may  be  roughened  and  cracked  even  by 
the  above  method  of  sterilizing.  Frequently  they  are 
simply  thoroughly  cleaned  with  soap  and  water,  held  for 
one  minute  in  boiling  water,  and  laid  in  alcohol  half  an 
hour  before  use. 

Rubber  catheters,  tubing,  and  similar  articles  are  so 
difficult  to  sterilize  with  any  certainty  that  if  used  for  an 


SUTURES   AND    LIGATURES  487 

infected  case,  they  should  be  reserved  for  the  individual 
use  and  destroyed  when  finished  with. 

Rubber  sheets  or  mackintoshes  are  not  usually  required 
to  be  sterile.  After  use,  however,  especially  after  an  in- 
fectious or  a  septic  case,  they  must  be  carefully  disinfected. 

Remove  organic  material  with  cold  water;  if  it  is  not 
practical  to  clean  them  immediately,  stained  rubber 
sheets  should  be  put  to  soak  in  cold  water  while  still  wet. 
This  will  dissolve  the  albumins  and  prevent  stain-marks. 

Scrub  with  soap  and  tepid  water  and  rinse  very  thor- 
oughly: sand-soaps  scratch  and  spoil  the  rubber  and  must 
not  be  used. 

Immerse  in  an  antiseptic  solution  for  a  specified  time — 
for  example,  in  formalin  (2  per  cent.)  for  one-half  hour. 

Rinse,  wipe,  and  hang  in  the  air  until  dry.  Avoid  fold- 
ing in  putting  away;  hang  over  a  wide  wooden  rail,  or  lay 
extended  on  an  unused  mattress. 

GLASS,   CHINA,  AND  ENAMEL  WARE 

Glass  and  china  are  easily  cracked  in  the  autoclave  if 
carelessly  packed  without  due  allowance  for  expansion 
(p.  452),  if  placed  directly  in  very  hot  water,  or  if  too  rap- 
idly cooled ;  otherwise  articles  of  glass,  china,  or  enamel- 
ware  can  equally  well  be  sterilized  in  the  autoclave,  by 
boiling,  or  by  soaking  in  a  strong  antiseptic,  such  as 
bichlorid  of  mercury  1 :  500  or  carbolic  acid  1 :  20  for  one 
hour,  or  formalin  2  to  5  per  cent,  for  half  an  hour.  Glass 
or  good  china  stand  sterilization  better  than  enamelware, 
which  either  with  heat  or  chemicals  quickly  loses  its  pol- 
ished surface.  Exposure  to  heat,  as  in  the  autoclave,  also 
seems  to  loosen  the  enamel  and  leave  it  liable  to  chip  easily, 
and  the  rough  surface  so  exposed  is  a  harboring-place  for 
dust. 

SUTURES  AND  LIGATURES 

Silkworm-gut  (fishing-gut)  is  the  ordinary  suture  or 
stitch  used  in  closing  wounds.  It  is  the  silk-producing 
gland  of  the  silkworm,  stretched  into  a  long  strand  and 
dried  while  fully  stretched.  It  forms  a  smooth,  white, 
strong  strand,  stiff  and  bristly  when  dry,  but  softened  by 


488      PREPARATION,    STERILIZATION   IN   SURGICAL   WORK 

hot  water.  The  strands  vary  from  12  to  18  inches  long, 
the  average  length  being  about  14  inches.  The  different 
thicknesses  cannot  be  accurately  assorted,  depending,  as 
they  do,  on  the  size  and  the  stretching  quality  of  the  gland. 
They  are  sold  in  three  sizes, — fine,  coarse,  and  medium, — 
with  an  extra  fine  and  an  extra  coarse  not  always  easy  to 
be  obtained. 

The  tied  ends  of  the  sutures  when  dry  are  sharp  and 
prickly;  where  this  may  cause  discomfort,  they  may  be 
clamped  with  shot. 

Silkworm-gut  is  not  absorbable,  and,  therefore,  must 
be  removed  when  the  incision  is  healed,  or  it  will  act  as  a 
foreign  body,  irritating  and  inflaming  the  tissues;  for  this 
reason  it  is  not  used  for  the  deeper  tissues.  As  silkworm- 
gut  causes  a  certain  amount  of  scarring,  it  is  not  usually 
used  on  exposed  surfaces,  such  as  the  face  or  hands. 

Silkworm-gut  contains  in  itself  no  pathogenic  organisms, 
is  not  altered  by  exposure  to  dry  heat,  nor  spoilt  by  boiling, 
and  is  permeable  to  antiseptics;  it  is,  therefore,  readily 
sterilized. 

To  prepare:  Wash  by  scrubbing  on  a  board  with  hot 
soap  and  water,  and  rinse  thoroughly  under  running  cold 
water. 

Fold  in  a  piece  of  gauze,  a  dozen  strands  at  a  time,  put 
up  in  the  usual  wrapper  of  double  muslin,  and  sterilize 
in  the  autoclave  with  the  other  dressings  for  twenty  min- 
utes under  15  pounds  pressure. 

Immediately  before  use  soften  by  immersion  in  boiling 
water  for  one  minute.  (Longer  immersion  will  not  injure 
the  suture.) 

A  second  process  of  sterilization  is  as  follows:  Place 
so  many  strands,  six  or  twelve,  together,  for  example,  in 
glass-stoppered  jars  filled  with  a  1 :  500  solution  of  bichlorid 
of  mercury;  the  solution  should  be  hot.  After  twenty- 
four  hours  empty  the  solution  and  fill  two-thirds  full  with 
pure  alcohol,  taking  care  to  cover  the  strands;  boil  ten 
minutes  in  a  water-bath.  The  strands  are  kept  in  the 
jars  in  which  they  are  sterilized  until  they  are  to  be  used, 
when  they  are  softened  by  immersion  for  not  less  than  a 
minute  in  boiling  water. 


SUTURES  AND  LIGATURES  489 

Many  hospitals  sterilize  the  silkworm-gut  only  by  boil- 
ing ten  minutes  just  before  use;  soda  must  not  be  used  in 
the  water.  Repeated  boiling  is  not  considered  to  injure 
the  suture. 

In  threading  the  needle  pass  about  one  inch  through  the 
eye,  bend  sharply,  and  twist  together  twice  to  prevent 
slipping. 

Silk. — A  good  quality  of  silk,  both  black  and  white,  of 
various  sizes,  is  frequently  used  for  suturing,  especially 
in  operations  about  the  face,  where  it  is  important  to 
avoid  scarring.  For  different  purposes  plain,  twisted,  or 
braided  silk  is  preferred.  Silk  is  also  used  in  work  on 
delicate  tissue,  such  as  the  intestines,  kidneys  and  gall- 
bladder, and  other  internal  organs,  and  for  tying  pedicles, 
etc.  Its  advantages  are  that  it  is  strong  and  very  pliable, 
and  that  the  knot  does  not  slip.  Like  silkworm-gut,  it  is 
non-absorbable.  , 

To  prepare,  for  convenience,  strands  27  inches  long  are 
wound  on  separate  glass  spools.  Four  or  six  spools  of  one 
size  of  silk  are  prepared  and  placed  end  to  end  in  a  wide 
glass  tube,  a  wad  of  cotton  being  laid  at  the  lower  end  and 
between  each  spool,  to  avoid  knocking  together;  the  tube  is 
also  plugged  with  cotton.  The  size  of  the  silk  should  be 
marked  on  the  tube. 

Silk  may  be  sterilized  by  boiling  by  the  fractional 
method,  but,  as  a  rule,  the  tubes,  filled  and  plugged,  are 
placed  in  the  autoclave  and  the  silk  sterilized  twenty  min- 
utes with  the  other  dressings. 

The  sterilized  tubes  may  be  kept  conveniently  in  cov- 
ered glass  jars. 

Horsehair. — Sutures  of  horsehair,  taken  from  the  horse's 
tail,  are  not  much  used  at  the  present  day,  but  are 
still  occasionally  preferred  for  fine  stitching  on  the  face 
or  scalp.  The  sutures  are  removed  at  an  early  date. 
Horsehair  forms  a  fine  elastic  suture,  but  breaks  easily 
under  tension.  They  require  careful  preparation,  espe- 
cially on  account  of  the  risk  of  possible  contamination  by 
the  tetanus  bacillus,  one  of  the  spore-producing  organisms. 

To  prepare:  Separate  coarse  from  fine  hairs,  and  cut 
in  strands  of  equal  length  (16  to  20  inches);  knot  12 


490      PREPARATION,   STERILIZATION   IN   SURGICAL  WORK 

together  at  either  end,  and  scrub  on  a  board  with  hot 
soap  and  water.  Rinse  under  running  water.  Cut  the 
strands  an  inch  below  each  knot,  and  twist  into  a  loose 
coil.  Place  the  coils  in  sterile,  glass-stoppered  jars,  filled 
with  sufficient  pure  alcohol  to  cover  the  coil,  and  sterilize 
in  the  autoclave,  or,  if  preferred,  place  the  closed  bottles 
in  a  water-bath  and  boil  ten  minutes  on  three  successive 
days. 

Keep  in  the  alcohol  jars  until  required.  In  threading 
the  needle  a  surgeon's  knot  is  tied  below  the  eye  to  pre- 
vent it  slipping. 

Silver  Wire. — Wire  sutures  of  pure  virgin  silver  are 
used  chiefly  in  suturing  bone,  and  are  removed  when  their 
purpose  is  accomplished. 

To  prepare:  Scrub  on  a  board  with  hot  soap  and  water, 
rinse,  dry,  wind  in  a  loose  coil,  and  keep  in  a  clean,  covered 
box  in  a  dry  place.  To  sterilize,  boil  with  the  instruments 
in  a  1  per  cent,  soda  solution. 

In  threading,  pass  half  an  inch  through  the  needle,  bend 
sharply,  and  twist  once. 

Silver  in  itself  has  certain  antiseptic  properties,  and  the 
sutures  have  an  antiseptic  influence  on  the  tissues  with 
which  they  come  in  contact. 

Catgut. — Catgut  is  obtained  from  the  small  intestine  of 
the  sheep.  Its  chief  value  over  other  sutures  is  that, 
being  an  organic  substance,  it  is  absorbable  by  the  human 
tissues,  and  can,  therefore,  be  used  for  ligatures  and  for 
deep  sutures  which  are  to  be  retained. 

The  preparation  of  catgut  is  not  invariably  left  to  the 
nursing  staff;  in  many  hospitals,  and  usually  in  private 
practice,  it  is  procured,  fully  prepared  and  sterilized,  in 
sealed  tubes  from  surgical  dealers. 

Very  careful  preparation  and  sterilization  indeed  are 
necessary,  for  the  reason  that  the  tissues  of  the  sheep  may 
contain  organisms  that  produce  disease  in  man,  and  the 
catgut  itself,  being  an  organic  substance,  can  act  as  a  me- 
dium, under  suitable  conditions,  for  the  development  of 
germs  with  which  it  conies  in  contact;  such,  for  example,' 
as  the  pus-producing  organisms.  The  sheep  may  be 
infected  by  such  organisms  as  the  tetanus  and  the  anthrax 


SUTURES   AND    LIGATURES  491 

bacilli.  Both  these  varieties,  we  remember,  are  subject 
to  spore  formation  (p.  393);  the  methods  of  sterilization 
must,  therefore,  be  sufficient  to  destroy  spores.  At  the 
same  time  the  process  must  not  make  the  catgut  brittle 
or  weak,  nor  must  antiseptics  be  used  that  will  irritate  the 
tissues  into  which  the  catgut  is  introduced. 

If  catgut,  in  its  unprepared  state,  is  exposed  to  boiling, 
a  substance  named  collagen,  of  which  catgut  is  largely 
composed,  is  converted  into  gelatin,  completely  spoiling 
the  suture.  Dry  heat  does  not  alter  catgut  if  the  catgut 
itself  is  perfectly  dry;  the  least  moisture,  however,  is 
sufficient  to  act  upon  the  collagen  and  convert  it  into 
gelatin  when  the  catgut  is  exposed  to  heat.  Catgut  is, 
in  fact,  an  extremely  difficult  substance  to  prepare,  re- 
quiring conscientious  care  at  every  step. 

Properly  prepared  catgut  is  free  from  fat  or  moisture, 
pliable,  smooth,  and  tough.  A  ligature  that  feels  hard  and 
wiry  is  usually  brittle,  and  should  be  discarded.  In  tying, 
good  ends  must  be  left  to  the  knot,  as,  in  contact  with  the 
warmth,  moisture,  and  cell  activity  of  the  human  tissues, 
catgut  swells,  and  if  allowance  is  not  made,  the  knot  may 
slip.  This  is  the  common  cause  of  post-operative  hemor- 
rhage. 

In  most  of  the  processes  of  preparation  the  catgut  is 
wound  on  glass  spools;  care  must  be  taken  to  wind  in  a 
single  layer,  otherwise,  where  the  strands  cross,  the  pressure 
prevents  the  necessary  drying  and  hardening  from  taking 
place,  and  a  weak  spot  results,  which  will  break  under 
strain.  The  coil  is  most  conveniently  cut  into  three 
lengths. 

Catgut  comes  in  various  sizes,  numbered  from  00  to  8. 
In  some  of  the  preparation  methods  the  time  required  for 
immersion  in  the  agent  varies  with  the  different  sizes. 
The  minimum  is  reckoned  for  00,  the  maximum  for  8. 
The  sizes  most  used  are  from  0  to  4. 

Prepared  catgut  is  conveniently  stored  in  wide-mouthed 
glass  bottles  with  ground-glass  stoppers.  These  must  be 
carefully  washed  and  sterilized  before  being  used.  All 
necessary  handling  during  the  process  of  preparation  and 
sterilization  must  be  done  with  sterile  forceps.  The  best 


492      PREPARATION,   STERILIZATION   IN   SURGICAL   WORK 

media  for  storing  catgut  are  alcohol,  glycerin,  or  simple 
oils;  these  have  no  action  on  the  collagen,  provided  all 
moisture  has  been  removed. 

The  following  methods  are  in  use  in  many  hospitals 
where  the  catgut  is  prepared  by  the  nursing  staff,  and  can 
l)e  carried  out  without  special  apparatus: 

Plain  Catgut.— Cut  the  strand  into  three  lengths  and 
wind  in  a  single  layer  on  glass  spools;  place  the  spools  in  a 
sterile  jar,  cover  with  ether,  and  stopper  closely;  leave  for 
twenty-four  hours,  shaking  the  jar  at  intervals.  This 
process  removes  the  fat  and  so  prepares  the  catgut  for 
the  antiseptic.  Pour  off  the  ether  and  refill  the  jar  with 
1:500  solution  of  bichlorid  of  mercury  in  pure  alcohol; 
replace  the  stopper  and  stand  aside  for  one  hour. 

Transfer  the  spools  to  sterile,  wide-mouthed  bottles,  and 
cover  with  pure  alcohol;  stopper  closely  and  place  in  a 
water-bath;  boil  ten  minutes  on  three  successive  days. 
By  this  process  the  collagen  has  been  removed  and  the 
boiling  will  not  injure  the  catgut.  The  boiling  is  repeated 
each  time  before  use.  The  catgut  is  not  taken  from  the 
jar  until  required  for  use. 

Other  methods  of  preparation  have  for  their  object  the 
making  of  the  catgut  resistant  for  a  longer  time  to  absorp- 
tion by  the  tissues.  According  to  the  process  used,  liga- 
tures may  be  produced  that  will  remain  unabsorbed  from 
two  to  six  weeks.  This  is  desirable  in  many  important 
operations  on  the  internal  organs.  The  agents  used  are: 
iodin,  cumol,  formalin,  chromic  acid,  tannic  acid,  alum, 
and  others. 

The  date  of  absorption  cannot  be  measured  absolutely, 
as  the  process  may  be  modified  by  many  conditions,  such 
as  the  state  of  the  health,  the  condition  of  the  tissues,  etc. 

The  following  are  the  processes  in  common  use  where 
such  preparation  is  carried  out  by  the  nursing  staff: 

Iodized  Catgut. — Cut  the  strand  in  three  lengths;  make 
a  loose  coil  of  each  over  three  fingers;  thread  the  coils  on 
one  strand,  like  beads  on  a  string. 

2.  Place  in  a  glass  beaker,  capacity,  500  c.c. 

3.  Place  the  beaker  on  a  sand-bath  or  asbestos  mat  in 
a  hot-air  oven  (as  used  in  laboratories). 


SUTURES  AND  LIGATURES  493 

4.  During   fifteen   minutes   raise   the   temperature   to 
100°  C.;   maintain   at   this   temperature  fifteen  minutes 
further  (dry  heat). 

5.  Pour  liquid  albolene  into  the  beaker,  sufficient  com- 
pletely to  cover  the  catgut,  and  raise  the   temperature 
gradually  during  fifteen  minutes  to   140°  C.;  maintain 
fifteen  minutes  and  then  turn  off  the  flame  (moist  heat). 

6.  Leave  to  cool  for  twelve  hours;  relight,  and  bring  to 
140°  C.  in  fifteen  minutes;   maintain  at  140°  C.  fifteen 
minutes  further;  turn  off  the  light. 

7.  Leave  to  cool  for  three  hours;  lift  out  the  coils  with 
sterile  forceps,  cut  the  connecting  thread,  and  drop  into 
wide-mouthed,    stoppered   bottles,    previously   sterilized, 
containing  Jg  per  cent,  solution  of  iodin  in  pure  alcohol. 

The  catgut  is  ready  for  use  after  forty-eight  hours  in  the 
iodin  solution  (Philadelphia  Poly  clinic  and  others). 

Formalin  Catgut.— 1.  Wind  a  whole  coil  of  catgut  on 
any  convenient  cylinder  (such  as  an  empty  ether  can)  in 
a  single  layer. 

2.  Soak  in  formalin  (3  per  cent.)  for  from  one  and  one- 
half  (size  00)  to  five  hours  (size  8),  according  to  the  size 
of  the  catgut.     The  catgut  will  be  brittle  if  left  too  long 
in  the  formalin. 

3.  Wash  in  running  water  for  twice  the  time  that  the 
catgut  has  been  in  the  solution. 

4.  Roll  in  a  single  layer  on  a  wide  muslin  bandage,  and 
dry  in  the  sun  and  open  air.     Finally — 

5.  Wind  in  a  small  coil  round  three  fingers  and  store 
in  glass-stoppered  jars. 

Catgut  prepared  in  this  way  may  be  boiled  without 
injury,  as  the  gelatinizing  substance  has  been  removed. 
The  ligatures  are  boiled  fifteen  minutes  before  use. 

A  Second  Process. — After  the  immersion  in  formalin 
and  washing  in  running  water,  as  in  the  first  process, 
transfer  directly  to  sterile,  glass-stoppered  jars;  fill  with 
sufficient  pure  alcohol  completely  to  cover  the  catgut; 
place  the  jars  in  a  water-bath  and  boil  fifteen  minutes  on 
three  successive  days.  In  place  of  the  pure  alcohol  some 
use  a  10  per  cent,  solution  of  glycerin  in  pure  alcohol. 

Chromicized  Catgut. — For  this  process  a  special  glass 


494      PREPARATION,    STERILIZATION   IN    SURGICAL   WORK 

spool  is  used,  with  a  notch  on  either  flange,  by  which  the 
catgut  is  kept  stretched  and  prevented  from  shrinking. 

1.  Cut  the  coil  in  two  lengths,  wind  each  tightly  in  a 
single  layer  on  one  of  the  reels,  pass  each  end  through  its 
notch,  and  secure  by  passing  one  end  through  the  barrel 
and  tying  both  together. 

2.  Immerse  the  spools  for  from  twenty-four  hours  to 
three  days,  according  to  the  size  of  the  catgut,  in  a  chromic 
acid  solution,  as  follows: 

Bichromate  of  potash 1.5  gm. 

Glycerin  and  pure  carbolic,  each 10.0  c.c. 

Water 1000.0  c.c. 

3.  Remove  and  drain  for  a  few  hours. 

4.  Immerse  the  spools  in  1 :  500  solution  of  bichlorid  of 
mercury  in  pure  alcohol  for  six  days. 

5.  Transfer  with  sterile  forceps  to  sterile,  wide-mouthed 
bottles,   cover  with  pure   alcohol,   and   stopper  closely. 
Chromicized  catgut  can  also  be  boiled  without  injury. 
It  is  boiled  for  fifteen  minutes  before  use. 

Instead  of  using  the  bichlorid  solution,  the  chromicized 
catgut  may  be  treated  with  3  per  cent,  formalin,  as 
described,  using  the  second  process,  and  stored  in  a  10 
per  cent,  alcoholic  solution  of  glycerin. 

Cumol  Catgut. — Cumol,  a  chemical  compound  with  a 
boiling-point  of  165°  C.,  is,  at  the  present  day,  much  in 
favor  as  a  preparation  for  catgut  ligatures.  It  dissolves 
the  fat  in  catgut,  but  unless  carefully  used  is  liabje  to 
make  it  brittle  and  useless.  To  avoid  this,  the  catgut 
must  be  very  slowly  dried  by  carefully  graduated  dry 
heat  before  the  cumol  is  added;  if  this  is  done,  a  glue-like 
substance  forms  on  the  gut  which  will  keep  it  supple. 

Cumolized  catgut  is  most  conveniently  prepared  in  a 
special  sterilizer,  with  which  full  directions  are  given. 
The  preparation  may,  however,  also  be  carried  out,  using 
a  sand-bath  and  a  glass  beaker.  The  beaker  should  have 
a  cardboard  top,  through  a  hole  in  the  center  of  which  a 
thermometer  is  passed,  in  order  to  ascertain  the  tempera- 
ture at  each  step,  which  is  of  the  first  importance.  As 
cumol  is  highly  inflammable,  the  beaker  should  be  cov- 


DUSTING-POWDERS  495 

ered  with  copper-wire  netting  to  prevent  accidents.  The 
bottom  of  the  beaker  is  covered  with  a  layer  of  cotton, 
on  which  the  catgut,  wound  and  stretched  on  the  special 
glass  spools  just  described,  is  placed. 

The  first  process  is  to  dry  the  catgut.  Placing  the  appa- 
ratus over  a  gas  Bunsen  burner,  the  temperature  is  slowly 
raised  to  80°  C.,  as  follows: 

First      hour..  .  .  20°  C. 


Second 
Third 
Fourth 
Fifth 

Sixth 


40°  C. 
55°  C. 
70°  C. 
80°  C. 
80°-85°  C. 


By  the  end  of  the  sixth  hour  the  catgut  should  be  free 
from  moisture  and  ready  for  the  cumol. 

Seventh  hour :  Lower  the  light  and  add  cumol  at  a  tem- 
perature of  100°  C.  sufficient  to  cover  the  catgut.  Bring 
the  temperature  to  165°  C.  and  maintain  at  this  tempera- 
ture for  one  hour. 

Pour  off  the  cumol  and  keep  in  the  sand-bath  at  a  tem- 
perature of  100°  C.  for  two  hours,  in  order  to  dry  the 
catgut. 

Store  either  dry,  in  sterile  tubes,  or  in  pure  alcohol  in 
the  usual  stoppered  bottles. 

Kangaroo  Tendon. — In  special  cases,  where  it  is  desir- 
able to  retain  a  suture  for  an  unusually  long  period,  as, 
for  example,  in  suturing  bone,  a  suture  made  from  kan- 
garoo tendon  may  be  preferred  in  place  of  catgut.  The 
methods  of  preparation  are  the  same  as  for  catgut.  Usu- 
ally the  chromic  acid  preparation  is  preferred. 

DUSTING-POWDERS 

Some  preparations,  such  as  iodoform,  are  actively  germ- 
ioidal  only  when  in  contact  with  wound  secretions;  others 
are  mixed  with  non-antiseptic  preparations,  such  as  starch 
powder,  etc.  These  may  be  contaminated  with  bacteria 
from  dust,  etc.,  and  should,  therefore,  be  sterilized  regu- 
larly in  the  autoclave  and  kept  closely  covered.  If  per- 
forated metal  covers  are  used  for  the  dusting  pots,  they 


496      PREPARATION,   STERILIZATION   IN   SURGICAL   WORK 

(the  covers)  should  be  boiled  daily  and  the  pots  kept  in 
wide  covered  glass  jars. 

lodoform  is  altered  if  subjected  to  a  temperature  of 
239°  F.  or  over.  The  powder  is  sterilized  in  the  auto- 
clave at  7  pounds  pressure  for  forty-five  minutes.  Dur- 
ing sterilization  iodin  vapor  is  given  off;  this  should  be 
allowed  to  escape  by  covering  the  jar  only  with  a  fold  of 
gauze;  if  retained  in  the  jar,  the  whole  powder  will  become 
iodized  and  useless  for  its  purpose.  When  this  has  hap- 
pened, the  iodoform  is  turned  brown. 

OILS  AND   OINTMENTS 

These  may  be  sterilized  twenty  minutes  in  the  auto- 
clave at  15  pounds  pressure. 

If  to  be  sterilized  by  boiling,  place  the  jar  or  flask  in  a 
water-bath  of  warm  water,  bring  to  boiling-point,  and 
maintain  half  an  hour.  Cool  slowly  to  avoid  cracking. 
Glycerin  is  usually  sterilized  in  this  way.  The  boiling 
should  be  repeated  on  three  successive  days,  as  oils  and 
ointments  readily  harbor  germs.  Jars  and  flasks  should 
be  only  two-thirds  full.  Flasks  are  plugged  with  absorb- 
ent cotton;  jars  should  have  the  lids  lightly  adjusted  over 
a  double  layer  of  gauze.  Lids  should  not  be  screwed  on 
or  the  glass  jar  may  break. 

Small  bottles  or  jars  previously  sterilized  may  be  conve- 
niently filled  for  use  in  the  wards  from  the  sterile  supply. 

SOLUTIONS 

Provided  the  vessels  are  sterile  and  that  the  solutions 
are  made  from  filtered  sterile  water,  no  further  steriliza- 
tion is  necessary  for  the  ordinary  dressing  solution. 

Any  solution,  however,  that  is  to  be  introduced  directly 
into  the  circulation  (as  normal  salt  solution),  or  used  to 
irrigate  a  closed  cavity  (as  the  peritoneum),  must  be  ster- 
ilized in  the  autoclave  twenty  minutes  under  15  pounds 
pressure  or  by  boiling  by  the  fractional  method. 

DRESSINGS 

Loose-meshed,  bleached  gauze  is  now  universally  used 
for  surgical  dressings  and  for  sponges.  Hospitals,  as  a 


DRESSINGS  497 

rule,  have  their  own  special  shapes  and  sizes  for  these 
dressings.  Wherever  possible,  the  cut  edges  should  be 
turned  in  to  avoid  ravelings,  which  might  adhere  to  raw 
surfaces.  This  is  especially  necessary  in  making  gauze 
sponges. 

For  sterilization  a  known  quantity  of  cut  gauze  is 
wrapped  in  a  double  cover  of  unbleached  muslin  and  ster- 
ilized in  the  autoclave  for  twenty  minutes  at  15  pounds 
pressure.  Not  more  than  is  necessary  for  one  complete 
dressing  should  be  done  up  in  one  wrapper.  Dressings, 
such  as  perineal  pads,  eye-pads,  etc.,  may  be  done  up  six 
or  twelve  in  one  wrapper,  the  wrapper  so  folded  that  only 
one  pad  is  unfolded  at  a  time.  Sponges  are  put  up  in 
packets  of  6  to  12  as  required.  The  contents  of  all  pack- 
ages should  be  marked  on  the  wrapper  in  blue  pencil. 
Besides  the  dressings  cut  to  cover  wounds,  gauze  is  used 
to  establish  drainage  and  to  pack  cavities.  Gauze  band- 
ages, one  and  one  and  one-half  inches  wide,  are  used  for 
this  purpose,  to  avoid  the  raw  edges  of  the  cut  gauze. 
These  are  cut  into  lengths  of  one  yard  and  packed  into 
sterile  glass  tubes,  which  are  stoppered  with  absorbent 
cotton.  They  are  sterilized  with  the  other  dressings  in 
the  autoclave. 

Towels,  sheets,  caps,  gowns,  etc.,  are  wrapped,  like  the 
dressings,  in  covers  of  double  muslin  and  sterilized  twenty 
minutes  in  the  autoclave  at  15  pounds  pressure. 

All  sterile  articles  should  be  kept  in  their  covers  until 
actually  required  for  use.  It  is  the  only  certain  way  of 
keeping  them  from  possible  contamination  by  dust  or 
handling.  Portions  of  dressings  not  used  must  be  col- 
lected and  resterilized. 

Medicated  Gauze. — For  special  purposes  dressings  and 
packings  of  medicated  gauze  are  used — gauze,  that  is  to 
say,  impregnated  with  some  agent,  usually  either  anti- 
septic or  stimulant.  During  the  antiseptic  period  of  sur- 
gery gauze  impregnated  with  carbolic  acid,  with  bichlorid 
of  mercury,  and  other  antiseptic  preparations  were  much 
in  favor;  at  the  present  moment  iodoform  gauze  is  the 
only  one  of  such  dressings  much  in  use.  It  is  chiefly 
used  in  the  packing  and  dressing  of  tubercular  sinuses. 

32 


498      PREPARATION,   STERILIZATION   IN   SURGICAL  WORK 

lodoform  Gauze. — lodoform  gauze  may  be  sterilized 
in  the  autoclave  at  low  pressure  (7  pounds  for  forty-five 
minutes),  when  prepared,  but  there  is  always  the  risk,  if 
the  temperature  is  accidentally  raised,  of  the  whole  dress- 
ing being  spoiled  by  the  action  of  the  iodin  vapor  given 
off  by  the  iodoform  at  239°  F.,  as  described  above.  The 
composition  of  the  dressing  is  altered,  and  the  dressing 
useless  for  its  purpose. 

To  avoid  this  risk,  each  of  the  articles  to  be  used  may 
be  previously  sterilized  separately  and  the  whole  process 
carried  out  with  strict  aseptic  precautions.  All  the  ves- 
sels are  sterile,  and  the  nurse  scrubs  up  her  hands  as  if  for 
an  operation,  and  wears  gown  and  gloves. 

Gauze  is  cut  to  the  necessary  sizes  and  shape,  and  ster- 
ilized in  the  usual  way. 

Make  an  emulsion  as  follows,  the  ingredients  previ- 
ously sterilized: 

lodoform  powder  and  glycerin,  equal  parts,  to  which 
some  add  bichlorid  of  mercury,  5  grains  to  every  half  pint 
of  the  mixture. 

Rub  together  in  a  mortar;  when  perfectly  smooth,  add 
to  the  whole  mixture  half  the  quantity  of  pure  alcohol; 
mix  by  shaking  thoroughly  in  a  good-sized  bottle. 

Place  the  gauze  in  the  mortar,  pour  on  the  emulsion, 
and  work  with  the  hands  until  thoroughly  impregnated. 

Fold,  roll  lightly,  and  store  in  closely  stoppered  jars  of 
dark  glass.  If  dark  glass  is  not  available,  the  jars  should 
be  kept  in  a  dark  closet,  away  from  direct  sunlight,  which 
will  iodize  the  iodoform,  or  the  jars  may  be  covered  with 
asbestos  paper. 

Different  prescriptions  are  used  in  various  hospitals  for 
the  emulsion,  thus: 

(a)  Iodoform 1  ounce. 

Salt  solution  (9: 1000) 5  ounces. 

Castile  soap,  sufficient  to  make  thick  suds. 

(6)  lodoform 1  pound. 

Glycerin 1  pint. 

Boiling  water 2  pints. 

Castile  soap,  sufficient  to  make  thick  suds. 


SEA-SPONGES  499 

Plain  gauze  after  use  can  be  washed,  sterilized,  and 
used  again,  thus  diminishing  the  expense  of  dressings. 

In  one  hospital  that  makes  a  practice  of  washing  the 
gauze  the  following  procedure  has  been  found  practical : 

The  used  gauze  is  collected,  at  the  dressings  or  opera- 
tions, in  stout  mesh  bags,  such  as  are  used  in  machine 
laundries  for  the  washing  of  small  articles;  the  bags  must 
not  be  more  than  half  full.  The  bags  are  kept  until  col- 
lected in  covered  garbage-cans.  They  are  collected  twice 
a  day-,  placed  directly  in  one  of  the  laundry  tubs,  and 
washed  in  the  following  order: 

Cold  rinse 5  minutes. 

Hot  suds 10 

Hot  rinse 5         " 

Cold  rinse 5         " 

Boiled 5        " 

The  bags  are  then  drained  and  hung  in  the  drying  closet 
until  partially  dry;  while  still  damp  the  gauze  is  pulled 
into  shape,  trimmed,  and  packed  for  sterilization  like 
other  dressings.  The  only  drawback  to  the  process  is  the 
labor  involved  in  pulling  the  gauze  into  shape  again. 
The  washed  gauze  is  softer  and  more  free  from  fluff  than 
the  unwashed  gauze. 

SEA-SPONGES 

Sea-sponges  are  not  entirely  out-of-date.  On  account 
of  their  absorbent  property,  they  are  frequently  preferred 
in  operations  complicated  by  copious  mucoid  secretions,  as, 
for  example,  on  the  mouth  and  tongue,  or,  more  rarely, 
the  cervix. 

In  preparing,  care  must  be  taken  to  remove  thoroughly 
the  sand  and  lime  deposits  found  in  sea-sponges. 

1.  Beat  with  a  wooden  mallet  to  break  up  and  remove 
shells,  sand,  and  dirt;  wash  at  intervals  in  cold  running 
water,  soaking  in  cold  water  between  the  times.     Repeat 
until  free  of  dirt. 

2.  Soak  in  1  :  64  solution  of  hydrochloric  acid  to  dissolve 
lime  deposits. 

3.  Soak  in  a  saturated  solution  of  permanganate  of 
potash  fifteen  minutes. 


500      PREPARATION,    STERILIZATION   IN   SURGICAL   WORK 

4.  Soak  in  a  saturated  solution  of  oxalic  acid  until 
bleached — usually  about  half  an  hour. 

5.  Wash  in  two  waters. 

6.  Soak  for  twenty-four  hours  in  bichlorid  of  mercury 
1  :  1000. 

7.  Transfer  to  sterile  jars,  fill  the  jars  with  carbolic 
1  :  20,  and  cover   closely.     Keep  in   this   solution   until 
required. 

Before  use  the  sponges  are  wrung  out  in  normal  salt 
solution  and  washed  in  the  same  during  use. 

As  they  will  not  keep  in  this  way  more  than  about  two 
weeks,  only  a  small  number  should  be  kept  ready  for  an 
emergency.  If  used  for  a  clean  case,  they  may  be  washed 
and  resterilized.  After  an  infectious  case  they  should  be 
discarded. 

HAND-BRUSHES  AND  NAIL-CLEANERS 
After  use,  wash  under  running  cold  water  and  soak  in 
formalin  (2  per  cent.)  for  thirty  minutes;  wash  in  hot  suds 
and  dry  quickly,  to  prevent  softening  of  the  bristles. 

Put  up  in  convenient  packages  and  sterilize  with  the 
dressings  in  the  autoclave.  During  an  operation  they 
are  usually  kept  in  an  antiseptic  solution.  A  fresh  set 
should  be  put  out  for  each  operation. 

CULTURES 

Sterilized  articles  should  be  examined  from  time  to  time 
to  insure  that  the  process  is  adequate.  To  do  so,  a  cul- 
ture is  taken  of  the  material  to  be  examined.  A  small 
fragment  of  the  sterile  object  is  removed,  with  strict  asep- 
tic precautions,  and  dropped  carefully  into  a  tube  of  sterile 
culture  bouillon.  The  tube  is  plugged  with  cotton  (which 
should  be  ignited  for  a  moment  before  being  replaced), 
and  kept  in  a  dark  place  at  a  temperature  of  about  98°  F. 
for  twenty-four  hours.  If  the  specimen  is  sterile,  the 
bouillon  remains  clear.  If  it  becomes  cloudy,  the  micro- 
organisms should  be  developed  and  examined  in  the  usual 
way  (p.  406).  Cultures  should  also  be  taken  from  time 
to  time  from  the  finger-nails  of  those  engaged  at  an  opera- 
lion. 


CHAPTER  XIV 

SURGICAL    TECHNIC    AND    MINOR    SURGICAL 
EVENTS 

Principles  Governing  Technic — Duties  of  Sterile  and  Unsterile 
Nurses — Technic  in  Preparation  of  the  Skin — Surgical  Dressings — 
Hypodermoclysis — Intravenous  Infusion — Venesection — Injection  of 
Antitoxin  Serums — Exploration — Lumbar  Puncture — Venous  Punc- 
ture for  Blood  Culture — Parac en tesis— Aspiration  of  Chest-wall;  of 
Pericardium. 

PRINCIPLES   OF  TECHNIC 

HAVING  carefully  prepared  and  sterilized  everything 
that  is  to  come  in  contact,  direct  or  indirect,  with  the  open 
wound,  we  have  now  to  consider  how  to  keep  all  "sterile" 
during  an  operation,  a  surgical  dressing,  or  other  surgical 
procedure. 

At  the  present  day  the  methods  used  have  become  a 
species  of  drill,  in  which  each  has  a  definite  part  to  play. 
From  early  days  it  is  to  be  recommended  that  proba- 
tioners should  be  taught  their  drill  until  it  is  performed 
with  mechanical  precision.  The  demonstration  can  be 
carried  out  in  the  class-room  with  dummy  dressings. 
Some  nurses  will  at  once  grasp  the  principles  involved, 
but  they  will  work  better  and  more  quickly  for  having 
their  duties  well  defined;  others  will  require  to  be  drilled 
again  and  again  until  perfect,  but  under  present-day 
methods  it  is  far  too  important  a  point  to  be  left  to  pick 
up  in  any  haphazard  way. 

While  everything  that  comes  in  contact,  directly  or 
indirectly,  with  the  wound  must  be  surgically  clean, 
there  are  many  things  necessarily  involved  at  an  opera- 
tion, etc.,  that  are,  so  to  speak,  surgically  "dirty."  For 
example,  the  patient's  body,  with  the  exception  of  the 
field  of  operation;  the  gown  and  coverings  of  the  patient; 
the  table  and  stands;  the  outside  wrappings  of  sterile  dress- 

501 


502     SURGICAL  TECHNIC  AND   MINOR   SURGICAL  EVENTS 

ings;  spiggots  and  door-handles;  besides  bottles,  stoppers, 
exhaust  pumps,  and  any  appliance  that  it  may  be  imprac- 
tical or  unnecessary  to  sterilize. 

Sterile  and  Unsterile  Nurses. — To  overcome  this  dis- 
advantage in  carrying  out  surgical  technic,  as  we  call  it, 
these  unsterile  objects  must  be  handled  by  persons  who 
do  not  come  in  contact  with  the  open  wound.  In  tech- 
nical language,  the  assistants  at  an  operation,  etc.,  are 
divided  into  "clean"  or  "sterile,"  and  "dirty"  or  "unsterile." 

A  "clean"  nurse  is  one  whose  hands  are  "scrubbed  up" 
according  to  formula,  in  addition  to  which,  except  for  very 
minor  proceedings,  her  ordinary  dress  is  covered  with  a 
sterilized  gown ;  gloves  must  also  always  be  worn  where 
the  hands  have  to  come  in  contact  with  the  raw  surface  or 
with  discharges,  and  are  desirable  in  most  surgical  pro- 
ceedings. 

A  clean  nurse  is  no  longer  "clean"  if  she  touches  any 
unsterilized  object;  in  technical  language,  she  has  "broken 
her  technic";  an  unsterile  nurse,  if  she  touches  any  sterile 
object,  whether  with  her  hands  or  skirts,  has  opened  a 
channel  of  possible  infection  and  broken  the  technic  pos- 
sibly of  an  entire  operation.  An  unsterile  object  laid 
down  among  sterile  objects  must,  in  strict  technic,  be 
regarded  as  having  rendered  the  whole  unsterile.  Thus 
if  a  dirty  instrument  is  placed  in  a  tray  of  clean  ones,  the 
whole  must  be  resterilized.  Water  and  lotions  are  no 
longer  sterile  if  touched  with  the  unsterilized  hand,  as,  for 
example,  to  test  the  temperature,  or  if  an  unsterile  sponge 
or  instrument  is  thrown  into  the  basin;  dirty  instruments, 
etc.,  must  not  be  added  to  objects  in  process  of  sterilization; 
if  this  happens  accidentally,  the  whole  must  be  resterilized 
with  the  article  just  added. 

Constantly  a  nurse  meets  with  the  direction  "  with 
strict  aseptic  precautions";  the  measures  these  words 
are  intended  to  imply  should  present  themselves  to  her 
mind,  down  to  the  most  minute  detail,  without  hesitancy 
or  confusion.  While  there  are  always  several  ways  of 
attaining  results,  perfection  in  nursing  is  best  arrived  at 
by  teaching  one  way  thoroughly  and  leaving  little  for 
individual  initiation. 


PRINCIPLES   OF  TECHNIC  503 

A  practical  plan  in  teaching  technic  to  a  young  class 
of  probationers  is  to  smear  the  fingers  of  "  clean  "  and 
"  unsterile  "  nurses  respectively  with  rouge  and  with 
charcoal:  a  touch  in  the  wrong  place  is  then  quickly  de- 
tected. 

Strict  technic  is  not  possible  unless  two  work  together. 
In  certain  conditions,  as  on  night  duty  or  in  private  nurs- 
ing, this  may  be  impossible;  it  is  then  important  that  the 
nurse  should  understand  exactly  the  point  at  which  she 
must  prepare  her  hands  and  beyond  which  she  must  keep 
"  clean." 

The  duties  of  clean  and  unsterile  nurse  may  be  briefly 
detailed  as  follows: 

The  Clean  Nurse  (Nurse  No.  i). — As  she  is  responsible 
for  the  dressing  (or  etc.),  she  first  collects  and  arranges 
conveniently  all  that  is  to  be  used,  and  places  articles  to 
be  boiled  in  the  sterilizer.  At  this  point  she  summons  the 
unsterile  assistant  and  prepares  her  own  hands  according 
to  formula,  and  after  this  she  is  "  clean,"  and  must  touch 
nothing  but  the  sterilized  objects  and  the  actual  area  of 
operation.  She  must  not,  for  example,  help  to  move  the 
patient,  touch  the  bed-clothes,  or  the  outside  of  lotion 
bowls  or  bottles,  etc.,  open  a  door,  or  turn  on  a  spiggot; 
neither  must  she  touch  her  own  face  or  any  part  of  her 
dress  not  protected  by  a  sterile  gown.  If  a  sterile  gown  is 
worn,  it  is  put  on  after  her  hands  are  prepared;  the  gloves 
are  drawn  on  last  of  all. 

In  beginning  her  dressing,  etc.,  her  first  act  is  to  provide 
herself  with  a  sterile  area  to  protect  her  hands  and  sterile 
appliances  from  contact  with  unsterile  objects.  For  this 
purpose  sterilized  towels  are  used,  one  to  cover  a  table  on 
which  she  can  place  the  necessary  instruments  and  dress- 
ings, and  others  to  cover  the  area,  etc.,  in  the  immediate 
neighborhood  of  the  dressing,  disposing  them  above, 
below,  and  on  either  side  of  the  part  to  be  dressed.  She 
must  remember  once  the  towels  have  been  placed  on  an 
unsterile  object,  only  the  upper  surface  remains  sterile. 
She  finishes  her  preparation  by  taking  from  the  open 
packets  handed  her  by  her  unsterile  helper  the  necessary 
dressings  and  appliances. 


504      SURGICAL  TECHNIC   AND   MINOR   SURGICAL   EVENTS 

Her  remaining  duties  vary  with  the  requirements  of  the 
individual  process.  She  remains  clean  until  the  open  sur- 
face, puncture,  etc.,  is  covered  by  the  dressing.  Before 
applying  the  outer  bandage  after  a  dressing,  she  removes 
her  gloves,  or,  if  these  are  not  worn,  rinses  her  hands 
thoroughly  in  antiseptic  lotion,  otherwise  the  bandage 
itself  may  be  infected  with  any  organism  present  in  the 
wound  secretions,  and  become  a  channel  of  infection. 

For  the  same  reason,  before  leaving  the  bedside,  after 
any  except  surgically  clean  proceedings  (such  as  hypoder- 
moclysis),  the  hands  should  be  immersed  as  a  matter  of 
routine  for  one  full  minute  in  the  antiseptic  solution  pre- 
ferred, and  must  be  washed  and  disinfected  again,  accord- 
ing to  formula,  before  any  other  object  is  touched. 

In  minor  surgical  proceedings,  if  by  accident  technic  is 
broken,  the  hands  must  be  immersed  a  full  minute  in 
antiseptic  solution  before  resuming;  should  a  sponge  or 
instrument  that  is  to  come  in  actual  contact  with  the 
tissues  touch  an  unsterile  object,  it  must,  in  strict  technic, 
be  discarded,  or  the  whole  process  of  sterilization  repeated ; 
for  this  reason,  and  to  provide  against  accidents,  it  is  best, 
in  preparing  for  catheterization,  hypodermoclysis,  explor- 
ation, etc.,  to  prepare  two  catheters  or  two  needles,  rather 
than  risk  delay  if  a  second  is  required. 

Should  the  clean  nurse  be  obliged  to  handle  an  unsterile 
object,  for  example,  a  flask  or  the  air-pump  of  an  aspirator, 
the  object  must  be  covered  temporarily  with  a  sterile  towel 
or  piece  of  gauze.  If  she  touches  a  dressing  not  strictly 
sterile,  she  uses  sterile  forceps  and  discards  them  after  use. 

The  danger  of  indirect  infection  is  often  overlooked. 
For  example,  a  nurse  may  have  dressed  an  infected  wound 
with  strict  aseptic  technic,  and,  before  disinfecting  her 
own  hands,  afterward,  may  touch  a  spiggot,  a  door-handle, 
or  perhaps  the  patient's  bed-clothes;  on  the  spot  she 
touches  some  of  -the  organisms  will,  in  all  probability,  be 
deposited.  A  second  person  may  touch  the  same  spot,  her 
fingers  will  become  infected,  and  she  may  quite  innocently 
convey  the  infection  in  this  way  to  a  third.  The  risk  is 
very  much  lessened  if  forceps  are  used  instead  of  fingers, 
and  gloves  are  worn. 


PRINCIPLES   OF   TECHNIC  505 

The  Unsterile  Nurse  (No.  2). — The  duties  of  the  un- 
sterile nurse  should  be  as  clearly  defined  as  those  of  the 
sterile  nurse.  The  unsterile  objects  which  it  is  her  part 
to  handle  include,  besides  the  patient  and  the  bed-clothes, 
the  wrappers  containing  the  sterilized  objects,  mackintoshs 
or  Kelly  pad,  bottles,  flasks,  the  outside  of  lotion  bowls, 
douche-cans,  or  pitchers,  bandages,  splints,  and  other 
appliances,  and  the  receiver  for  the  soiled  dressings. 
These  she  should  place  together  conveniently  for  her  to 
handle,  and  out  of  the  way  of  the  sterile  table. 

While  the  clean  nurse  is  scrubbing  her  hands,  nurse  No. 
2  arranges  the  patient  in  proper  position,  pours  out  lotions, 
adjusts  mackintoshes  or  Kelly  pad,  if  required,  and  unpins 
the  sterilized  packages,  holding  them  open  for  No.  1  to 
take  from  them  what  she  wants. 

If  the  skin  is  to  be  prepared,  the  preliminary  scrubbing 
and  shaving  is  the  part  of  the  unsterile  nurse;  she  follows 
it  with  an  alcohol  wash  (p.  473),  and  if  there  is  any  delay, 
covers  the  part  with  a  towel  wrung  out  of  bichlorid  of 
mercury  1  :  1000;  the  sterile  nurse  begins  the  disinfection 
by  repeating  the  alcohol  wash,  or,  if  another  formula  is 
used,  with  the  application  of  the  antiseptics.  For  the  pre- 
liminary scrubbing  mackintoshes  are  used  to  cover  the 
clothing — one,  or  two,  as  required;  they  may  then  be 
removed  or  covered  with  sterile  towels,  as  indicated  by 
circumstances.  They  should,  for  example,  be  retained 
for  douching,  irrigation,  or  if  there  is  likelihood  of 
bleeding. 

The  clean  nurse  prepared,  nurse  No.  2  fastens  the  gown 
behind,  since  No.  1  can  hardly  do  this  without  touching  her 
ordinary  dress.  She  then  unpins  and  opens  the  packages 
and  hands  them  to  No.  1,  beginning  with  the  towels  for 
the  sterile  area;  finally  she  brings  the  boiled  articles  from 
the  sterilizer.  These  may  be  carried  in  the  tray  on  which 
they  were  sterilized,  or  removed  to  a  sterile  towel  with  a 
pair  of  sterile  forceps.  Throughout  the  process  she  fol- 
lows what  No.  1  is  doing  carefully,  anticipating  her  wants, 
and  guarding  herself  carefully  from  touching  any  sterile 
object,  even  with  a  view  to  helping. 

Frequently  a  limb  may  have  to  be  held,  movements 


506      SURGICAL   TECHNIC    AND   MINOR   SURGICAL   EVENTS 

restrained,  or  such  an  object  as  a  tourniquet  controlled, 
in  the  immediate  neighborhood  of  the  sterile  area.  Nurse 
No.  2  must  then  place  her  hands  underneath  the  sterile 
coverings,  taking  care  not  to  touch  the  upper  surface  of 
the  towels  or  to  get  in  the  way  of  the  clean  operator. 

If  the  unsterile  nurse  has  to  touch  a  sterile  object,  as, 
for  example,  in  transferring  an  instrument  from  the 
sterilizer,  or  taking  a  towel  or  sponge  from  the  sterile 
packet,  she  uses  a  pair  of  sterile  forceps.  An  old  pair  of 
forceps  should  be  kept  standing  in  antiseptic  lotion  beside 
the  sterilizer. 

In  all  aseptic  proceedings  a  basin  of  antiseptic  lotion, 
usually  bichlorid  of  mercury,  1 :  1000,  hot ,  should  be  placed 
in  readiness  in  case  the  technic  is  accidentally  broken. 
With  two  nurses  working  together  this  should  not  happen. 
The  replenishing  of  the  lotion  bowls  is  the  duty  of  No.  2. 
It  is  not  necessary  or  practical  to  keep  the  outside  of 
lotion  bowls  sterile;  in  handling  the  bowls  care  must  be 
taken  not  to  hold  them  by  the  brim,  since  the  inside  must 
be  kept  sterile. 

Volatile  drugs,  such  as  alcohol,  ether,  etc.,  are  used  when 
required  directly  from  the  flasks.  The  necessary  quantity 
is  poured  by  the  unsterile  nurse  onto  a  sterile  sponge  held 
by  the  clean  nurse. 

In  pouring  solutions,  etc.,  from  bottles,  the  brims  of  the 
bottles  should  be  wiped  free  of  any  possible  dust  with  a 
sponge  soaked  in  a  little  of  the  solution;  the  stopper 
should  be  held  in  the  little  finger  of  the  left  hand,  to  pre- 
vent it  coming  in  contact  with  other  objects. 

In  giving  an  aseptic  douche,  irrigation,  or  hypodermo- 
clysis,  the  rubber  tubing  is  best  divided  into  two  parts 
connected  by  a  piece  of  glass  tubing;  the  lower  length 
alone  is  handled  by  the  sterile  nurse,  and  kept  strictly 
sterile  throughout.  Although  the  whole  apparatus  is 
sterile  to  start  with,  the  douche-can,  flask,  etc.,  and  the 
upper  length  of  tubing  are  most  conveniently  handled  by 
the  unsterile  nurse. 

The  principal  aseptic  measures  in  which  nurses  are  con- 
stantly engaged  are :  the  preparation  of  the  field  of  opera- 
tion; minor  dressings;  catheterization;  hypodermoclysis; 


PRINCIPLES   OF   TECHNIC  507 

to  which  may  be  added,  assisting  at  minor  surgical  pro- 
cedures in  the  ward. 

It  is  an  immense  help  that  the  technic  required  for  each 
of  these  proceedings  should  be  written  down.  The  direc- 
tions should  include  a  list  of  the  articles  required,  any 
special  method  for  sterilizing  the  articles,  the  formula 
required  for  preparing  the  hands,  the  area  of  the  skin  to 
be  prepared,  and,  for  convenience,  the  position  in  which 
the  patient  must  be  placed. 

The  technic  should  be  reduced  to  the  simplest  com- 
patible with  good  standards;  elaborate  technic  is  too 
often  an  excuse  for  carrying  it  out  imperfectly.  Where 
only  one  nurse  is  available  for  aseptic  measures,  as  may 
happen  in  private  nursing  or  on  night  duty,  it  is  important 
that  the  nurse  should  understand  exactly  the  point  at 
which  she  must  "scrub  up,"  and  beyond  which  she  must 
keep  "dean." 

For  the  proceedings  that  are  constantly  called  for,  the 
preparation  of  the  skin,  catheterization,  and  hypodermo- 
clysis,  etc.,  trays  may  be  kept  ready  with  all  the  articles 
necessary. 

Cleansing  the  Hands. — The  technic  required  for  the 
cleansing  of  the  hands  should  be  typed  and  posted  in  a 
conspicuous  place,  preferably  over  the  wash-stands,  since 
the  importance  of  this  part  of  all  technic  cannot  be  over- 
estimated. The  hands  of  nurses  and  dressers  are  con- 
sidered, without  doubt,  the  most  common  channels  of 
infection  in  hospital  work,  and  the  weak  link  in  the  chain 
of  aseptic  methods. 

Two  formulas  for  preparing  the  hands  are  in  use  in 
the  wards:  The  first,  Formula  A,  should  be  the  same  as 
that  required  for  the  purpose  in  reparing  for  operations; 
this  is  used  in  the  preparation  for  minor  operations,  for 
important  dressings,  and  other  circumstances  especially 
indicated.  A  second  formula  (B),  a  modification  of  the 
first,  is  used  in  preparing  for  minor  dressings,  catheteriza- 
tion, vaginal  douching,  and  similar  proceedings.  The 
directions  for  special  technic  should  state  which  formula 
is  to  be  used. 


508   SURGICAL  TECHNIC  AND  MINOR  SURGICAL  EVENTS 

Formula  A. — Turn  the  sleeves  up  above  the  elbows,  and  scrub 
hands  and  forearms  ten  minutes  in  hot  soap  and  water,  using  nail- 
brush, changing  water  frequently;  clean  round  the  nails  with  blunt 
orange-wood  stick.  (The  formula  of  sterilization  used  in  the  general 
operating-room  follows.)  (See  p.  471.) 

Formula  B. — Turn  the  sleeves  up  above  the  elbows  and  scrub  the 
hands  and  well  above  the  wrists  three  minutes  in  hot  soap  and  water, 
using  hand-brush;  change  water  once;  clean  round  nails  with  blunt 
orange-stick.  Immerse  in  hot  solution  of  bichlorid  of  mercury  (or 
Harrington's  solution,  etc.)  for  two  minutes;  rub  the  solution  briskly 
into  the  skin. 

The  mechanical  scrubbing  is  the  most  important  part  of  either 
formula. 

N.  B.:  To  lessen  the  risk  of  establishing  a  channel  of  infection, 
the  hands  must  be  immersed  and  rubbed  in  the  antiseptic  solution 
for  one  full  minute  before  leaving  the  patient's  side  wherever  a 
raw  surface  has  been  exposed,  if  the  hands  have  come  in  contact 
with  organic  secretions,  and  after  changing  the  linen  or  removing  the 
bed-pan,  etc.,  from  an  infectious  case,  after  which  they  must  imme- 
diately be  again  cleansed  according  to  formula. 

The  custom  of  using  gloves  for  all  aseptic  proceedings 
is  a  great  safeguard  against  infection;  in  the  wards  the 
mended  rubber  gloves  may  be  used,  or  cheap  cotton 
gloves,  which  can  be  washed  and  boiled. 

PREPARATION   OF  THE  SKIN 

The  preparation  tray  should  contain: 

1  pitcher  (for  sterile  water). 

2  bowls  (for  water  and  lotion). 


Nail-brush. 


Sterilized. 


Packet  of  6  towels  (or  2  packets  of  4) . 
2  packets  of  6  gauze  sponges  each. 
A  razor. 

Nail-scissors  and  nail-cleaner. 

Small  flasks  containing  respectively  tincture  of  green 
soap,  alcohol,  and  ether. 
8-oz.  bottle  of  bichlorid  of  mercury  1 :  500. 
2  pieces  of  mackintosh  sheeting. 
Bowl  for  soiled  sponges,  etc. 

The  pitcher  and  bowls  can,  of  course,  be  added  to  the 
tray  when  required.  Very  hot  water  is  added  to  the 
solution  to  make  it  the  required  strength.  The  mackin- 
toshes are  arranged  to  protect  the  bedding  and  night-dress 


DRESSINGS  509 

during  the  scrubbing,  and  are  removed  or  covered  with 
sterile  towels  during  the  disinfecting  process.  If  one 
nurse  works  alone,  she  prepares  her  own  hands  after  the 
scrubbing  and  shaving  and  first  wash  of  alcohol,  covering 
the  area  in  the  interval  with  a  towel  wrung  out  of  the 
bichlorid  lotion.  Where  the  condition  of  the  patient  does 
not  admit  of  this  delay,  she  is  usually  allowed  to  prepare 
her  hands  before  beginning;  she  then,  after  the  scrub- 
bing process,  soaks  her  hands  for  one  minute  in  the  hot 
bichlorid  solution  and  puts  on  sterile  gloves  for  the  process 
of  disinfection. 

In  preparing  the  skin,  Formula  B  is  used  for  the  hands, 
when  the  process  is  to  be  repeated  before  the  operation; 
if  the  operation  is  to  follow  immediately,  Formula  A  is  used. 
In  this  circumstance,  if  the  nurse  or  dresser  is  to  aid  as 
clean  assistant  at  the  operation  (minor),  the  hands  must 
again  be  washed  (Formula  B)  after  the  preparation;  if  time 
does  not  permit,  the  hands  are  soaked  in  bichlorid  of 
mercury  and  briskly  rubbed  one  minute,  and  a  fresh  pair 
of  sterile  gloves  are  put  on. 

DRESSINGS 

In  present-day  methods  a  general  dressing-room,  fitted 
for  any  emergency,  is  a  common  part  of  hospital  equip- 
ment ;  the  patients  are  taken  from  the  wards  to  have  their 
dressings  changed,  and  most  minor  surgical  measures  are 
likewise  carried  out  with  more  privacy  than  can  be  looked 
for  in  a  ward. 

In  a  large  school  it  is  not  always  easy  to  give  each 
nurse  her  full  time  in  this  department,  and  there  is  further 
the  disadvantage  that,  where  all  is  kept  prepared  for 
every  sort  of  contingency,  the  pupil  nurse  loses  sight  of 
what  is  essential  for  each  different  event,  and  is  at  a  loss 
when  on  her  alone  falls  the  responsibility  of  preparing 
one  or  the  other.  Thus  the  very  perfection  of  equipment 
may  be  a  stumbling-block  in  the  training  unless  steps  are 
taken  to  counteract  this  drawback  by  individual  teaching. 

For  an  ordinary  dressing  the  following  articles  should 
be  prepared : 


510      SURGICAL  TECHNIC  AND  MINOR  SURGICAL  EVENTS 


In  sterile  packages. 


Towels  (4  a  good  average). 

Sponges  (12). 

Gauze  dressing. 

Absorbent  cotton  pads. 

Dressing  scissors,  probe,  and  forceps  (boiled  ten  min- 
utes), bandage,  and  safety-pins. 

Bowl  of  sterile  water  or  antiseptic  solution  (in  case  the 
dressing  should  stick  or  the  wound  require  washing). 

Bowl  of  antiseptic  solution  for  the  hands. 

Receptacle  for  soiled  dressings. 


Fig.  155. — A  surgical  dressing. 

Where  there  are  cavities  requiring  to  be  treated  with 
injections  of  special  preparations,  such  as  iodoform  emul- 
sion, peroxid  of  hydrogen,  etc.,  a  glass  syringe  and  small 
measure-glass  or  gallipot  are  further  required,  and  may  be 
boiled  with  the  instruments.  A  tube  of  gauze  packing 
should  also  be  prepared. 

If  irrigation  is  necessary,  the  douche-can  and  tubing 
are  prepared  and  wrapped  until  required  in  a  sterile  towel, 
together  with  a  convenient  flat  bowl,  usually  of  the  kind 
known  as  kidney  shaped;  this  latter  is  boiled  with  the 
instruments  and  kept  sterile  throughout.  A  Kelly  pad 


DRESSINGS  511 

or  a  piece  of  rubber  sheeting  should  be  put  in  readiness 
for  all  irrigations. 

In  preparing  for  a  dressing  after  an  operation,  a  pair 
of  scissors  with  sharp  points  and  an  extra  pair  of  forceps 
should  invariably  be  ready,  in  case  a  stitch  should  re- 
quire to  be  removed  unexpectedly.  Sterilization  cannot 
with  safety  be  hurried,  and  neither  patient  nor  surgeon 
should  be  called  on  to  wait  for  what  a  little  foresight 
would  have  had  in  readiness. 

Where  an  incision  is  to  be  made,  the  following  should 
be  prepared,  in  addition  to  those  mentioned  above.  All, 
of  course,  are  sterilized: 

Knife. 

Sharp  scissors. 

2  artery  forceps. 

Surgical  needle. 

Catgut  ligature. 

Suture,  either  of  silk  or  silkworm-gut. 

If  an  abscess  cavity  is  to  be  opened,  there  should  also 
be  added  curet,  drainage  tubing,  and  tube  of  gauze  packing. 

In  many  instances  the  knife  only  may  be  used,  but  in 
preparing  the  above,  all  emergencies  are  provided  for, 
such,  for  example,  as  severing  a  blood-vessel,  or  the  neces- 
sity for  closing  part  or  all  of  an  incision — circumstances 
again  where  sterilization  cannot  well  be  waited  for. 

It  will  also  probably  be  necessary  to  have  ready  the  local 
anesthetic.  For  clean  incisions,  punctures,  and  similar 
proceedings,  anesthetics,  such  as  cocain,  eucain,  etc.,  are 
generally  administered  by  hypodermic  along  the  line  of 
incision,  and  a  hypodermic  charged  with  the  necessary 
amount  should  be  in  readiness;  where  an  abscess  is  opened, 
freezing  is  the  usual  form  of  local  anesthesia  (p.  364). 

For  a  dressing  the  hands  are  prepared  by  Formula  B, 
if  gloves  are  worn;  if  not,  Formula  A  must  be  used;  a  gown 
also  should  be  worn.  Where  several  dressings  follow  each 
other,  the  hands  are  cleaned  by  Formula  B  between  each 
dressing,  and  always  immersed  in  the  antiseptic  solution 
a  full  minute  before  leaving  the  bedside.  The  instruments 
used  must  also  be  cleaned  and  resterilized  between  dress- 
ings. Two  sets  are  necessary,  in  order  to  avoid  delay. 


512      SURGICAL  TECHNIC   AND   MINOR   SURGICAL   EVENTS 

The  minor  dressings  intrusted  to  nurses  are  usually  of 
the  chronic  variety  of  wounds  with  discharging  surfaces. 
The  surface  is  cleaned  with  sterile  water,  or,  more  usually, 
with  antiseptic  solution.  In  cleansing  a  wound,  the 
surrounding  area  must  first  be  cleaned,  washing  always 
away  from  the  wound,  and  the  raw  surface  last.  Sponges 
are  wrung  out  as  dry  as  possible,  and  each  sponge  is  dis- 
carded after  using  once.  In  the  first  treatment  of  a  wound 
due  to  an  accident,  where  the  surrounding  tissue  is  dirty, 
the  actual  wound  should  be  covered  with  a  sponge  soaked 
in  an  antiseptic,  while  the  area  round  is  thoroughly  cleaned, 
usually  with  soap  and  water.  In  removing  a  dressing  or 
packing  that  has  become  dry,  force  must  not  be  used; 
not  only  will  pulling  cause  needless  pain,  but  delicate 
granulations  will  be  destroyed  and  troublesome  bleeding 
may  be  started.  The  dressing  should  be  moistened  until 
it  comes  away  easily. 

In  packing  a  cavity  or  sinus,  no  rule  can  be  laid  down; 
in  some  cases  just  sufficient  is  required  to  establish  drain- 
age and  keep  the  surfaces  apart;  in  others  pressure  is  ap- 
plied by  packing  a  cavity  firmly.  The  tube  of  packing  is 
held,  and  the  cotton  plug  removed  by  the  unsterile  nurse; 
the  clean  nurse  draws  out  the  length  she  requires  with 
sterile  forceps,  and  cuts  it  with  sterile  scissors,  taking  care 
not  to  come  in  contact  with  the  outside  of  the  tube; 
holding  the  strip  with  the  forceps  in  her  left  hand,  she 
introduces  the  packing  little  by  little  into  the  cavity  with 
the  probe.  The  strip  must  not  come  in  contact  with  the 
surrounding  tissue  or  even  with  the  sterile  towels,  since 
during  the  dressing  these  may  very  easily  become  contami- 
nated with  any  organism  present  in  the  wound.  She 
should  also,  in  removing  packing,  hold  the  soiled  gauze 
so  that  it  does  not  fall  on  the  area  round  the  wound, 
which,  if  technic  is  strictly  followed,  should  remain 
sterile. 

Nurses  must  be  taught  to  use  forceps  and  not  the 
fingers  in  removing  and  applying  dressings  and  in  cleansing 
wounds.  A  nurse's  training  should  make  her  fastidious 
to  the  last  degree  in  keeping  her  hands  from  possible  con- 
tact with  infectious  organisms. 


DRESSINGS  513 

In  applying  a  dressing,  just  sufficient  for  the  purpose 
and  no  more  should  be  used.  If  oozing  is  expected,  the 
gauze  dressing  is  reinforced  with  pads  of  absorbent  cotton; 
the  bandage  should  be  applied  firmly,  but  not  tightly, 
and  be  sufficient  to  keep  the  dressing  in  place;  safety- 
pins  are  used  to  fasten  the  bandage,  except  for  band- 
ages about  the  head,  where  an  ordinary  long  pin  is  pre- 
ferred. 

Where  there  is  much  local  inflammation  and  in  condi- 
tions where  it  is  desirable  to  encourage  discharge,  the 
gauze  is  applied  wet;  sterile  water,  normal  salt  solution,  or 
an  antiseptic  lotion  may  be  used.  The  wet  dressing  is 
covered  with  a  light  cotton  pad  and  bandage,  or  it  may 
simply  be  held  in  place  with  a  bandage  and  kept  wet, 
either  by  constant  dripping  or  by  repeated  application 
of  the  lotion  used,  without  removing  the  bandage. 

In  most  cases  the  gauze,  either  wet  or  dry,  is  placed 
directly  on  the  wound  or  denuded  surface.  Where,  how- 
ever, the  granulating  surface  is  large,  as  in  burns,  for 
example,  it  is  covered  first  with  a  protective,  usually  rubber 
tissue,  in  order  to  prevent  injury  to  the  delicate  granula- 
tions if  the  gauze  should  stick  and  be  removed  with  force. 
The  tissue  should  either  be  perforated  freely,  or  it  may  be 
laid  on  in  strips,  leaving  a  small  space  between  the  strips, 
otherwise  the  dressing  will  act  as  a  poultice  and  encourage 
oversecretion. 

Collodion  Dressing. — Punctures  are  usually  closed  with 
a  collodion  dressing.  For  this  are  required: 

Small  bottle  of  flexible  collodion. 

Fragment  of  sterile  cotton. 

Sterile  applicator  or  brush. 

In  applying  the  dressing,  the  puncture  is  wiped  free  of 
blood,  and  a  thin  strand  of  cotton,  merely  a  few  threads, 
laid  over  the  small  wound.  Over  this  an  application  of 
collodion  is  painted,  and  then  a  second  layer  of  teased-out 
cotton  again  covered  with  collodion;  the  cotton  layer  and 
the  collodion  application  are  repeated  until  the  wound  is 
covered  sufficiently.  The  dressing  falls  off  in  a  day  or 
two,  but,  if  necessary,  it  can  be  dissolved  with  a  little  ether. 

The  practice,  not  unknown,  of  keeping  a  brush  in  the 

33 


514      SURGICAL  TECHNIC  AND  MINOR  SURGICAL  EVENTS 

collodion  bottle  and  applying  it  to  all  and  sundry  is  not 
only  dirty,  but  contrary  to  all  modern  principles  of 
technic. 

The  dressing  after  an  operation  is  not,  as  a  rule,  left  to 
the  nurse.  Her  duties  will  be  to  prepare  all  that  is  re- 
quired and  to  act  as  unsterile  assistant.  Unless  oozing 
occurs,  the  dressings  are  usually  left  undisturbed  until  the 
incision  is  healed.  Oozing  is,  however,  common  in  many 
conditions,  whether  of  blood  from  small,  unligated  vessels, 
serum,  or  solutions  where  cavities  have  been  freely  irri- 
gated. Some  surgeons,  for  example,  after  special  ab- 
dominal operations,  irrigate  the  peritoneum  with  salt 
solution,  leaving  a  certain  amount  in  the  cavity  to  be  ab- 
sorbed gradually.  When  oozing  occurs,  it  is  usual  to 
remove  the  top  dressings  and  apply  a  fresh  one  with  the 
same  aseptic  precautions  as  for  a  full  dressing.  The  nurse 
is  expected  to  watch  such  dressings  and  report  promptly 
if  oozing  is  taking  place,  as  once  it  reaches  the  outer  dress- 
ing a  channel  of  infection  is  opened  between  the  wound  and 
the  outside  air. 

Removal  of  Stitches. — Stitches  after  an  extensive  opera- 
tion are  commonly  removed  about  the  ninth  day,  though 
symptoms  of  tension  or  local  irritation,  or  the  necessity  for 
establishing  drainage,  may  require  their  removal  at  an 
earlier  date.  Stitches  about  the  face  are  removed  after  a 
much  shorter  interval,  in  order  to  avoid  scarring. 

After  stitches  are  removed,  an  incision  is  frequently 
supported  by  strips  of  adhesive  strapping.  A  small 
dressing  of  dry  gauze  is  generally  kept  over  an  incision 
until  the  scar  tissue  is  quite  strong. 

HYPODERMOCLYSIS  OR  SUBCUTANEOUS  INFUSION 

Infusion  of  hot  normal  salt  solution  into  the  subcu- 
taneous tissue  is  a  method  of  treatment  which,  at  the 
present  day,  a  nurse  is  constantly  required  to  carry  out. 

The  technic,  though  simple,  requires  attention  to  various 
details,  which,  if  not  clearly  grasped,  may  cause  confusion 
and  make  it  difficult  not  to  break  technic. 

The  hypodermoclysis  tray  should  contain: 


HYPODERMOCLYSIS   OR   SUBCUTANEOUS   INFUSION      515 


The   special  flask  or  douche-can  with 
length  of  rubber  tubing. 

Separate  short  length  of  rubber  tubing, 
with  glass  connection  tube,  to  be  kept  ster-     All    sterilized 
ile  throughout.  >    and  in  sterile 

Two    hollow,    sharp-pointed    needles,        wrappers, 
about  three  inches  long. 

6  gauze  sponges. 

2  towels. 

2  flasks  normal  salt  solution,  each  500  c.c. 

Collodion  dressing  (as  described),  to  which  are  added 
the  preparation  tray  (as  above),  a  bowl  of  lotion  for  the 
hands,  and  a  stand  from  which  to  hang  the  flask.  The 
flask  is  elevated  about  three  feet  above  the  bed. 


Fig.  156. — Giving  hypodermoclysis. 

The  solution  may  be  siphoned  directly  from  the  flask 
in  which  it  has  been  prepared,  using  a  glass  drinking  tube 
and  a  length  of  rubber  tubing,  to  which  the  hypodermo- 
clysis needle  is  attached.  Usually  in  hospital  work  a 
special  apparatus  is  reserved  for  hypodermoclysis.  Kelly's 


510      SURGICAL  TECHNIC   AND   MINOR  SURGICAL   EVENTS 

infusion  flask  (Fig.  156)  is  a  graduated  glass  flask  with  a 
narrow  neck  and  opening  at  the  lower  end,  like  that  of  a 
douche-can,  to  which  the  tubing  with  the  needle  is 
attached;  the  flask  is  graded  to  700  c.c.,  the  numbers  be- 
ginning at  the  top,  so  that  the  amount  given  may  be  read 
at  a  glance. 

The  hands  are  prepared  by  Formula  A  or  Formula  B, 
if  gloves  are  worn.  Gown  and  gloves  are  not  considered 
essential,  but  some  hospitals  insist  on  them  for  all  aseptic 
measures. 

On  the  side  of  the  "  clean  "  nurse  is  placed  a  table 
partly  covered  with  a  sterile  towel,  on  which  she  arranges 
the  gauze  sponges,  the  needles,  and  the  sterile  length  of 
tubing;  the  basin  of  hand  lotion  is  placed  on  the  uncovered 
part  of  the  table. 

On  the  opposite  side  the  unsterile  nurse  keeps  the 
preparation  tray,  irrigation  apparatus,  stand,  and  the 
flasks  of  normal  salt  solution,  one  hot  and  one  cold;  also 
the  sterile  packets  mentioned  until  the  clean  nurse  is  ready 
to  have  them  opened.  The  bandage  is  cut  from  the  brim 
of  the  flask,  but  the  cotton  stopper  is  kept  in  place.  The 
solution  is  heated  in  the  flask  over  a  gas  ring  or  in  a  water- 
bath. 

While  nurse  No.  1  is  preparing  her  hands,  nurse  No.  2 
carries  out  the  preliminary  preparations  of  the  skin  as  far 
as  the  first  alcohol  wash,  covering  the  area  with  a  bichlorid 
towel  or  a  piece  of  gauze;  shaving  is  not  necessary. 
Her  next  act  is  to  take  the  apparatus  from  its  wrapper, 
hang  it  on  the  stand,  clamp  the  tube,  and  fill  the  flask 
to  the  top  graduation  with  normal  salt  solution  of  the 
required  temperature.  The  outside  of  the  flask  and  tub- 
ing can  no  longer  be  considered  sterile,  and  are  not  touched 
by  nurse  No.  1. 

The  "  clean  "  nurse  begins  by  arranging  her  sterile 
area  and  finishes  the  preparation  of  the  skin,  i.  e.,  the  alco- 
hol and  ether  sponging  and  bichlorid  (1  :  1000)  flushing. 
She  next  attaches  the  needle  to  the  sterile  length  of  tubing, 
anil,  taking  the  glass  connection  tube  in  a  piece  of  sterile 
gauze,  joins  the  two  lengths  of  tubing.  The  clamp  is 
now  loosened. 


HVPODKRMOCLYSIS   OR   SUBCUTANEOUS   INFUSION      517 

Technic. — Before  inserting  the  needle,  the  clean  nurse 
allows  the  solution  to  run  freely  over  the  back  of  her  hand. 
This  is  both  in  order  to  expel  all  air  and  to  gage  the  tem- 
perature. The  temperature  should  be  from  114°  to  120°  F. 
The  usual  test  is  that  the  fingers  should  just  be  able  to  rest 
on  the  glass  flask.  The  temperature  may  also  be  tested 


Fig.  157. — Sites 'for  hypodermoclysis :  1,  Under  the  mammary 
glauds;  2,  in  the  subcutaneous  tissue  between  the  crest  of  the  ilium 
and  the  last  rib;  3,  in  the  subcutaneous  tissue  in  the  axillary  space; 
4,  in  the  subcutaneous  tissue  on  the  inner  surface  of  the  thighs 
(Morrow). 

by  keeping  a  long  dairy  thermometer  in  the  flask  during 
the  process  (Fig.  156).  This  must,  of  course,  also  be  sterile, 
and  should  be  kept  until  actually  required  in  an  antiseptic 
solution,  bichlorid  of  mercury  1  :  1000,  or  formalin  2  per 
cent.  From  time  to  time  it  may  be  necessary  to  add  hot 
solution  in  order  to  keep  up  the  temperature,  if  the  process 


Fig.   158. — Showing   two  needles    arranged    for    hypodermoclysis 
(Morrow). 

is  a  long  one  and  the  solution  runs  very  slowly.  The 
quantity  added  must  be  noted  accurately,  so  that  it  can 
be  known  how  much  the  patient  is  having. 

In  a  woman  the  site  usually  chosen  is  the  base  of  the 
breast;  other  favorable  sites  are  the  loose  skin  just  below 
the  axilla,  the  muscles  of  the  chest-wall  or  the  abdomen, 


518      SURGICAL  TECHNIC  AND  MINOR   SURGICAL  EVENTS 

the  thigh,  and  under  the  shoulder-blade.  The  needle  is 
introduced  horizontally  about  two-thirds  of  its  length,  and 
withdrawn  about  an  inch ;  while  inserting  the  needle,  the 
skin  is  held  stretched  by  the  left  hand. 

As  a  rule,  not  more  than  500  c.c.  should  be  introduced 
at  one  site.  The  solution  should  flow  slowly:  about 
twenty  minutes  is  required  to  introduce  500  c.c.  with  one 
needle.  If  desirable,  the  injection  may  be  given  at  two 
points  simultaneously,  as  in  both  breasts.  In  this  case 
a  T-shaped  glass  connection-tube  is  attached  to  the  upper 
length  of  rubber  tubing,  to  each  arm  of  which  a  sepa- 
rate length  of  rubber  tubing,  with  needle  attached,  is 
connected. 

The  infusion  started,  in  ordinary  circumstances  the  sec- 
ond nurse  may  be  dispensed  with  unless  she  is  required 
to  add  hot  solution.  The  clean  nurse  may  do  this  if  she 
is  careful  to  handle  the  flask  with  a  sterile  towel  or  piece 
of  sterile  gauze. 

Care  must  be  taken  to  withdraw  the  needle  while  there 
is  still  some  solution  remaining  in  the  flask.  The  tube  is 
clamped  before  the  needle  is  withdrawn,  in  order  to  avoid 
spilling  the  contents. 

A  nurse  may  frequently  have  to  give  normal  salt  in- 
fusion single  handed.  She  must  then  arrange  all  required, 
heat  the  solution,  and  fill  the  flask  before  "  scrubbing  up"; 
she  then  prepares  the  site,  as  this  involves  touching  un- 
sterile  objects;  after  this  part  is  complete,  she  rinses  her 
hands  in  the  bichlorid  solution,  puts  on  gloves,  and  re- 
peats the  alcohol  and  bichlorid  wash  before  introducing 
the  needle. 

By  this  process  the  salt  solution  is  introduced  into  the 
lymphatic  circulation,  and  conveyed  in  due  course  by  the 
lymphatic  vessels  to  the  blood-current;  some  of  the  solu- 
tion is  also  directly  absorbed  by  the  capillary  blood-vessels. 
The  tissues  immediately  round  the  puncture  become  in- 
filtrated with  the  fluid,  causing  a  circumscribed  swelling, 
which  is  gradually  absorbed  without  intervention.  A 
cotton  pad  and  bandage  will  hasten  the  absorption,  but 
this  is  not  generally  considered  necessary. 


INTRAVENOUS   INFUSION  519 

INTRAVENOUS  INFUSION 

Where  a  more  immediate  stimulation  to  the  circulation 
is  required,  the  salt  solution  may  be  injected  directly  into 
the  blood-current  by  opening  a  vein  in  the  forearm. 

In  addition  to  the  articles  required  for  hypodermoclysis, 
the  following  must  be  prepared: 

Scalpel. 

Aneurysm  needle  and  silk  ligature  (heavy). 

2  artery  forceps  and  catgut  ligature  (for  emergency). 

Surgical  needle  and  suture,  usually  silk  (medium  size, 
for  closing  the  incision). 

Scissors,  probe,  and  dressing  forceps. 

Intravenous  needle. 

Sterile,  flat-bottomed  basin. 

Gauze  dressing,  extra  sponges,  towels,  and  gauze  band- 
age. 

Tourniquet  or  muslin  bandage. 

The  intravenous  needle  is  a  fine  cannula,  3  or  4  inches 
long,  resembling  a  hypodermoclysis  needle,  but  slightly 
curved  and  with  a  blunt  point. 

The  operation  is,  of  course,  performed  by  a  doctor,  but 
a  clean  assistant  is  necessary  to  act  as  a  free  pair  of  hands. 
The  hands  are  prepared  by  Formula  A;  gown  and  gloves 
are  worn. 

The  surface  of  the  forearm  to  a  point  well  above  the 
bend  of  the  elbow  is  prepared  by  formula. 

The  instruments  are  arranged  on  the  sterile  table,  with 
the  gauze  sponges,  sterile  length  of  tubing,  and  sterile 
basin;  the  tourniquet,  bandage,  and  unopened  dressings, 
with  the  infusion  apparatus,  on  the  unsterile  side.  The 
preliminary  part  of  the  skin  preparation  is,  as  usual, 
carried  out  by  the  unsterile  nurse.  A  piece  of  rubber 
sheeting  is  kept  under  the  arm  during  the  whole  process; 
in  arranging  the  sterile  area,  one  towel  is  placed  below  the 
arm,  covering  the  rubber  sheeting;  one  covers  the  upper 
arm,  and  one  envelops  the  forearm.  The  sterile  basin 
is  placed  under  the  arm,  below  the  point  of  incision. 

Before  the  incision  is  made,  a  tourniquet  or  a  tight 
bandage  is  applied  round  the  upper  arm,  in  order  to  dis- 
tend the  veins  of  the  forearm.  The  tourniquet  should  be 


520      SURGICAL   TECHNIC   AND   MINOR   SURGICAL   EVENTS 

sufficiently  tight  to  distend  the  veins,  but  not  so  tight  as  to 
obliterate  the  pulse  at  the  wrist.  The  control  of  the  tour- 
niquet is  the  duty  of  the  unsterile  nurse;  in  order  to  be  free, 
she  must  previously  have  prepared  everything  necessary; 
packets  must  be  opened,  instruments  brought  from  the 
sterilizer,  the  apparatus  ready  for  use.  When  the  needle 
is  in  place,  the  tourniquet  is  gradually  loosened  and  finally 
removed.  The  nurse  is  careful  to  keep  her  hands  under- 
neath the  sterile  covering. 

The  sterile  assistant  will  be  required  to  keep  the  arm 
extended  and  still,  and,  if  the  patient  is  restless,  this  will 
take  her  entire  attention;  with  a  quiet  patient  she  can  spare 
a  hand,  if  desired,  to  help  with  any  sterile  object.  Before 
taking  her  place,  she  must  attach  the  needle  and  connect 
the  two  pieces  of  tubing  as  described,  and  also  see  that  the 
fluid  is  running  freely. 

Technic. — The  operation  is  as  follows:  the  vein  is  ex- 
posed by  a  light  incision;  the  silk  ligature  is  passed,  by  the 
aneurysm  needle,  under  the  vein,  below  the  point  to  be 
opened,  and  tied;  the  vein  is  then  opened,  and  the  cannula 
inserted,  making  sure  first  that  it  is  free  of  air,  and  running 
the  solution  over  the  back  of  the  hand  to  test  the  temper- 
ature. 

As  the  vein  fills,  the  tourniquet  is  slowly  loosened  and 
finally  removed,  leaving  the  unsterile  nurse  free  to  watch 
that  the  temperature  of  the  solution  is  kept  up,  and  help, 
if  necessary,  to  control  the  patient. 

About  500  c.c.  are  injected.  The  cannula  is  then 
withdrawn,  the  incision  closed,  usually  with  a  stitch,  and 
a  gauze  dressing  applied.  The  bandage  should  be  applied 
sufficiently  firmly  to  keep  the  elbow  extended,  and  the 
patient  should  be  cautioned  to  keep  the  arm  still  for  the 
first  day. 

Great  care  must  be  taken  to  stop  the  injection  while 
some  solution  is  still  in  the  flask,  otherwise  air  might 
be  forced  into  the  vein.  Air  in  any  quantity  forced 
suddenly  into  a  vein  causes  dilatation  of  the  left  chambers 
of  the  heart  and  of  the  pulmonary  vessels,  a  condition 
always  fatal,  and  usually  causing  death  in  a  few  minutes. 
Such  an  accident  could  take  place  only  through  gross 


INJECTION    OF   ANTITOXIN    SERUMS  521 

carelessness  in  such  a  process  as  intravenous  infusion, 
as,  for  example,  by  allowing  the  flask  to  become  perfectly 
empty  and  refilling  it  with  the  needle  in  place.  Still, 
nurses  should  be  cautioned  that  such  a  risk  exists. 

VENESECTION ;  PHLEBOTOMY 

Intravenous  infusion  is  also  carried  out  with  the  object 
of  diluting  the  toxins  in  the  blood  in  such  a  condition,  for 
example,  as  uremia.  A  certain  quantity  of  blood  is  then 
first  allowed  to  flow  from  the  vein  before  the  needle  is 
introduced.  A  flat,  graduated  vessel  should  be  sterilized 
and  placed  below  the  arm  at  the  point  of  incision,  so  that 
the  amount  withdrawn  can  be  estimated  at  a  glance. 
The  operation  is,  otherwise,  precisely  similar  to  that  just 
described. 

The  pulse  is  taken  and  recorded  before  and  after 
either  hypodermoclysis  or  intravenous  infusion,  and  a 
note  made  of  the  same,  with  the  hour,  the  amount  injected, 
and,  in  the  latter  case,  the  quantity  of  blood  withdrawn 
from  the  circulation. 

INJECTION  OF  ANTITOXIN   SERUMS 

The  injection  of  antitoxin  serum  (p.  425)  is  not  essentially 
different  from  other  hypodermic  injections.  The  syringe 
commonly  used  is  like  a  large  hypodermic  syringe,  with 
a  needle  three  or  four  inches  long.  For  more  convenient 
handling  the  needle  is  connected  with  the  syringe  by  a 
short  piece  of  rubber  tubing.  As  always,  special  care  is 
necessary  to  see  that  all  air  is  expelled,  and  the  needle 
filled  with  the  serum  before  it  is  inserted. 

The  articles  required  for  the  injection  are  as  follows: 

Syringe  and  needle. 

Vial  of  antitoxin  serum. 

Packet  of  towels  (2). 

Packet  of  gauze  sponges  (4). 

Preparation  tray. 

Collodion  dressing. 

Bowl  of  antiseptic  lotion  for  the  hands. 

The  hands  are  prepared  by  Formula  A;  gloves  and  gown 
are  worn. 


522      SURGICAL  TECHNIC   AND   MINOR  SURGICAL   EVENTS 

The  sites  usually  chosen  are  the  sides  of  the  abdominal 
wall  or  the  loose  tissue  under  the  shoulder-blade;  the  site 
is  prepared  according  to  formula. 

The  strictest  care  must  be  taken  to  keep  the  serum  from 
all  possible  contamination  during  the  process.  The  vial 
is  not  opened  until  the  hands  are  prepared  and  the  gown 
and  gloves  put  on;  the  syringe  is  filled  directly  from  the 
vial  after  every  part  has  been  carefully  sterilized.  Serum, 
being  highly  albuminous,  the  syringe  and  needle  must  be 
carefully  cleaned  in  cold  water  immediately  after  use,  to 
dissolve  the  albumin.  The  syringe  used  should  be  kept 
strictly  for  this  purpose. 

To  insure  absolute  sterilization,  the  diphtheria  antitoxin 


Fig.  159. — Mulford  antitoxin  phial. 

sent  out  by  the  Mulford  laboratories  is  put  up  in  sealed 
vials,  shaped  like  a  small  glass  syringe,  with  sterile  needle 
and  small  length  of  tubing.  A  mark  across  the  nozzle  of 
the  vial  indicates  the  point  at  which  it  is  to  be  broken 
and  the  needle  connected  with  the  vial  by  the  piece  of 
tubing.  The  drugs  administered  by  "  piqure  "  on  the 
continent  of  Europe  are  put  up  in  the  same  way.  Flasks 
of  normal  salt  solution,  500  c.c.,  are  also,  on  a  larger  scale, 
prepared  on  the  same  principle,  and  are  exceedingly  con- 
venient for  private  practice. 

MINOR  SURGICAL  PROCEDURES 

The  following  surgical  measures  are  frequently  performed 
by  the  surgeon  in  the  wards  or  the  patient's  room,  the 
nurse  usually  acting  as  unsterile  assistant.  If  required 


EXPLORATION  523 

to  help  as  "  clean  "  assistant,  she  scrubs  her  hands  by 
Formula  A,  and  puts  on  gown  and  gloves,  keeping  herself 
as  carefully  "  sterile  "  as  though  for  a  major  operation. 

As  unsterile  nurse,  she  will  be  required  to  prepare  all 
that  is  necessary,  keeping  sterile  and  unsterile  articles 
separate,  to  place  the  patient  in  the.  proper  position,  to 
carry  out  the  first  part  of  the  skin  preparation  as  described, 
and  to  remain  at  hand  to  handle  unsterile  objects,  to 
fetch  anything  accidentally  omitted,  or  to  support  the 
patient.  If  the  operation  is  carried  out  in  a  private  room, 
she  must  provide  the  necessaries  for  the  surgeon  to  pre- 
pare his  hands  according  to  formula,  and  have  gown  and 
gloves  in  readiness. 

The  preparation  of  the  patient's  skin  is  also  as  carefully 
carried  out  as  though  for  a  major  operation.  If  the 
nurse  is  in  any  doubt  as  to  the  area  to  be  prepared  or  the 
exact  position  required,  she  should  ask  to  be  shown  before 
the  surgeon  prepares  his  hands. 

The  possibility  of  shock  after  minor  operations,  per- 
formed without  a  general  anesthetic,  especially  those  that 
are  lengthy  and  fatiguing,  must  be  borne  in  mind.  An 
extra  blanket  and  hot-water  bag  should  be  in  readiness, 
and  a  stimulant  prepared,  such  as  whisky  or  brandy,  or 
a  hypodermic  syringe  charged  with  a  dose  of  strychnin 
or  of  atropin. 

If  local  anesthesia  by  hypodermic  injection  is  ordered, 
it  should  be  given  from  five  to  ten  minutes  before  the 
operation. 

EXPLORATION 

It  is  often  important,  for  diagnostic  purposes,  to  explore 
one  or  other  of  the  cavities  of  the  body,  either  to  determine 
the  presence  of  abnormal  fluid,  or  to  obtain  a  specimen  of 
a  fluid  for  microscopic  examination. 

A  large  hypodermic  syringe,  similar  to  that  used  for 
antitoxin  injection,  is  used;  the  needle,  about  four  inches 
long,  is  attached  to  the  syringe,  usually,  for  convenient 
handling,  by  a  piece  of  rubber  tubing.  It  is  of  the  first 
importance  that  these  should  be  absolutely  sterile  and  the 
needle  sharp  and  smooth. 


524      SURGICAL  TECHNIC   AND   MINOR   SURGICAL   EVENTS 

The  other  articles  required  are : 

Sterile  test-tube  plugged  with  cotton  (or  culture  tray). 
Collodion  dressing. 
Preparation  tray. 
Bowl  of  hand  lotion. 

The  patient  in  the  required  position  and  the  area  care- 
fully prepared,  the  needle  is  passed  into  the  cavity  and 


Fig.  160. — Method  of  performing  exploratory  puncture  of  the 
pericardium,  in  order  to  determine  the  nature  of  a  pericardial  exu- 
date  (Eisendrath). 

the  fluid  drawn  up  into  the  syringe.  The  puncture  is 
closed  with  collodion  dressing:  The  fluid  obtained  is 
transferred  to  the  test-tube  for  examination,  or  a  culture 
may  be  taken  (Chap.  XI). 

LUMBAR  PUNCTURE 

Puncture  of  the  spinal  canal,  with  the  object  of  removing 
a  portion  of  the  spinal  fluid,  is  employed  for  diagnostic 
purposes,  or  with  the  object  of  relieving  pressure  in  such 
disorders  as  meningitis,  hydrocephalus,  etc.  More  re- 


LUMBAR   PUNCTURE 


525 


cently,  the  process  has  been  used  for  the  injection  of  cer- 
tain remedies,  especially  tetanus  antitoxin. 


Fig.  161. — Lateral  position  for  spinal  puncture  (Morrow). 

In  quite  recent  days  anesthesia  has  been  produced  by 
injection  of  the  special  anesthetic  into  the  spinal  fluid. 
The  method  is  still  in  an  experimental  stage. 


Fig.  162. — Sitting  posture  for  spinal  puncture  (Morrow). 

The  process  is  similar  to  other  explorations,  and  the 
same  articles  are  required:  usually  an  exploration  needle, 
about  four  inches  long,  with  a  short  length  of  rubber  tubing 
attached,  is  used  without  the  syringe,  or  a  fine  trocar  and 


526      SURGICAL  TECHNIC   AND  MINOR   SURGICAL  EVENTS 

cannula  may  be  preferred.  Some  surgeons  make  a  small 
preliminary  incision  in  the  skin  before  inserting  the  needle. 
In  this  case  a  scalpel  will  be  required.  Two  sterile  test- 
tubes  should  be  prepared,  and  marked  1  and  2;  in  some 
conditions  it  is  important  to  distinguish  between  the  fluid 
which  flows  as  the  puncture  is  made  and  that  which  comes 
after.  As  these  tubes  are  most  conveniently  handled  by 
a  sterile  assistant  or  the  operator,  they  should  be  sterile 
outside  also.  The  needle,  or  trocar  and  cannula,  with 
the  tubing,  are  best  sterilized  in  the  autoclave  and  kept 


Fig.    163. — Spinal    puncture:   collecting   the   cerebrospinal  fluid 
(Morrow). 

wrapped  until  actually  to  be  used;  if  not,  they  should  either 
be  boiled  five  minutes  and  laid  in  alcohol  at  least  half  an 
hour  before  use,  or  simply  boiled  for  full  ten  minutes. 
The  hands  are  prepared  by  Formula  A;  gloves  and  gown 
are  worn. 

In  order  to  introduce  the  needle  between  the  vertebrae, 
the  spinal  column  must  be  fully  extended.  For  an  ex- 
ploratory puncture  the  patient  lies  on  his  side,  the  spine 
rounded,  the  head  and  shoulders  bent  forward.  In  con- 
ditions where  the  patient's  health  permits,  as  in  spinal 
anesthesia,  the  patient  usually  sits  upright,  the  arms 


BLOOD   CULTURE  527 

crossed  in  front,  and  the  head  and  shoulders  bent  forward. 
It  will  probably  be  necessary  to  support  the  patient  in  the 
required  position,  taking  care  to  keep  him  absolutely 
still  during  the  whole  process. 

The  puncture  is  most  frequently  made  at  a  point  just 
below  the  fourth  lumbar  vertebra,  which  may  be  taken  as 
the  center  of  the  area  to  be  prepared.  The  preparation 
must  be  carried  out  with  the  most  scrupulous  care. 

The  needle  introduced,  the  fluid  is  caught  in  the  sterile 
test-tubes,  one  or  two  as  required,  which  are  immediately 
plugged  with  sterile  cotton.  The  puncture  is  closed  with 
a  collodion  dressing.  The  quantity  of  fluid  removed,  with 
the  hour  of  the  operation,  should  be  carefully  noted  on  the 
chart. 

Simple  though  the  process  seems,  it  must  not  be  over- 
looked that  a  channel  of  communication  is  opened  into  the 
most  highly  organized  system  in  the  body,  and  that  in- 
fection will  certainly  be  followed  by  the  gravest  results. 
There  is  no  process  in  which  strict  aseptic  technic  is  more 
absolutely  necessary  in  every  detail. 

BLOOD   CULTURE 

In  certain  infectious  diseases  and  acute  septic  conditions 
bacteria  are  found  in  the  blood,  and  for  diagnostic  purposes 
it  may  be  desirable  to  make  a  culture  directly  from  the 
blood  of  the  patient.  For  this  purpose  a  small  quantity  of 
blood  is  withdrawn  from  a  vein.  Several  test-tubes  con- 
taining the  culture-media  preferred  must  be  in  readiness, 
as  it  is  important  the  blood  should  be  immediately  placed 
in  the  culture-media  before  it  has  time  to  clot  or  become 
in  any  way  altered. 

This  is  also  a  puncture  operation,  apparently  a  very 
simple  process,  but  in  which  want  of  care  in  strict  atten- 
tion to  detail  would  have  disastrous  results.  Strict 
asepsis  is  necessary  to  avoid  infection,  since  the  needle 
directly  enters  a  large,  blood-vessel,  and  further  care 
must  be  taken  that  no  air  is  allowed  to  enter  the  vein. 
The  risk  of  the  latter  is  not  great,  and  is  avoided  altogether 
if  the  vein  is  well  distended,  as  the  pressure  so  effected 


528      SURGICAL  TECHNIC   AND   MINOR    SURGICAL   EVENTS 

causes  the  blood  to  flow  into  the  needle  as  soon  as  it  is 
introduced  into  the  vein. 

The  articles  required  are: 

Small  exploring  needle  with  tube  attachment. 

Test-tube. 

Culture  tray. 

Preparation  tray  and  hand  lotion. 

Gauze  pad. 

Bandage. 

Tourniquet. 

The  needle  and  test-tube  should  be  as  carefully  steril- 
ized as  for  lumbar  puncture.  A  special  needle  attached  to 
a  small  glass  tube  is  frequently  used  in  place  of  the  ordin- 
ary exploring  needle. 

The  forearm  is  prepared  by  the  usual  formula,  and 
the  veins  distended  by  the  application  of  a  tourniquet 
or  tight  bandage  to  the  upper  arm.  As  in  intravenous 
infusion,  it  must  not  be  so  tight  as  to  obliterate  the  pulse 
at  the  wrist.  In  venous  puncture  the  tourniquet  is  re- 
tained until  the  process  is  over. 

The  hands  are  prepared  by  Formula  A:  gloves  and  gown 
are  worn;  the  unsterile  nurse,  besides  her  usual  duties,  will 
be  required  to  apply  the  tourniquet  and  to  hold  the  arm 
extended  (under  the  sterile  covering)  during  the  operation. 

When  the  vein  is  sufficiently  distended,  the  needle  is 
plunged  into  the  vein  without  a  preliminary  incision;  the 
blood  is  caught  in  the  sterile  test-tube,  and  transferred 
immediately  to  the  culture-media.  About  two  drams  is 
generally  taken.  The  wound  is  covered  with  the  gauze 
pad  and  a  firm  bandage;  sufficient  pressure  should  be 
applied  to  control  any  tendency  to  bleeding,  and  the  arm 
be  kept  extended  and  at  rest  for  some  time.  Discoloration 
or  tenderness  round  the  puncture  must  be  reported  at 
once.  Antiseptic  compresses,  either  hot  or  iced,  are 
usually  applied  if  such  a  condition  arises. 

PARACENTESIS,   OR  TAPPING 

Paracentesis,  or  tapping,  is  the  method  used  to  remove 
fluids  from  a  cavity  or  a  tumor  in  conditions  where  free 
opening  is  not  suitable.  The  cavities  of  the  pleura  or 


Sterile. 


PARACENTESIS,    OR  TAPPING  529 

the  pericardium  may  be  evacuated  in  this  way,  but  most 
frequently  paracentesis  is  performed  for  the  removal  of 
fluid  from  the  peritoneal  cavity,  in  the  condition  of  ascites, 
or  dropsy  of  the  abdomen. 

The  following  articles  are  required  for  paracentesis  of  the 
abdomen : 

Trocar  and  cannula,  with  long  piece  of 
fine  tubing. 

Scalpel. 

Needle  and   suture,   either  silk  or  silk- 
worm-gut. 

Abdominal  binder,  with  opening  in  the 
center. 

Towels,  4. 

Gauze  sponges,  6. 

Dressing  of  large  gauze  and  cotton  pads. 

Second  abdominal  binder. 

Small  empty  basin  (sterile). 

Slop-jar  or  bucket. 

Preparation  tray  and  basin  of  hand  lotion. 

As  the  operation  is  long  and  the  position  fatiguing,  it 
is  always  wise  to  have  a  stimulant  in  readiness. 

The  most  suitable  cannula  is  one  with  a  short  arm  near 
the  further  end,  to  which  the  tubing  can  be  adjusted  while 
the  trocar  is  in  place.  Otherwise  some  spilling  is  inevit- 
able when  the  trocar  is  withdrawn  before  the  rubber  can 
be  connected  to  the  cannula.  Trocar,  cannula,  and  tubing 
are  best  sterilized  in  the  autoclave. 

The  hands  are  prepared  by  Formula  A;  gown  and  gloves 
are  worn. 

Immediately  before  the  operation  the  urine  should  be 
voided,  as  the  bladder,  when  distended,  rises  above  the 
pubes  and  might  be  injured. 

The  patient  is  supported  in  the  upright  position  during 
the  process,  to  insure  better  drainage.  Some  doctors 
prefer  him  to  sit  in  an  arm-chair  or  on  the  edge  of  the  bed, 
the  feet  comfortably  supported  on  a  stool.  In  either  case 
he  must  be  made  thoroughly  comfortable,  with  pillows  and 
warm  coverings,  and  carefully  watched  for  symptoms  of 
fatigue  or  faintness.  Where  sitting  up  is  not  possible, 
34 


530      SURGICAL  TECHNIC   AND   MINOR   SURGICAL  EVENTS 

the  patient  lies  on  his  side,  the  abdomen  close  to  the  edge 
of  the  bed. 

A  rubber  sheet  is  arranged  to  protect  the  clothing  from 
getting  wet.  With  a  little  care  there  should  be  no  spilling. 
The  tubing  is  directed  into  the  stop-jar,  placed  conveniently 
on  the  floor  to  catch  the  fluid. 

The  whole  abdomen  is  prepared  according  to  formula, 
and,  except  in  the  case  of  children,  generally  shaved. 
The  preparation  over,  the  patient  is  placed  in  position,  and 
the  wide  sterile  binder  is  applied,  the  opening  over  the 
center  of  the  abdomen,  and  fastened  tightly  behind. 
The  antiseptics  are  again  applied  to  the  exposed  surface 
of  the  abdomen,  which  bulges  forward  through  the  opening 
in  the  binder;  two  sterile  towels  are  adjusted  over  the 
binder,  one  above  and  one  below  the  point  of  incision. 
A  minute  incision  is  made  in  the  skin,  the  trocar  and 
cannula  introduced,  and  the  trocar  withdrawn.  From 
time  to  time,  as  the  abdomen  empties,  the  binder  is  tight- 
ened from  behind.  When  sufficient  fluid  has  escaped,  the 
cannula  is  withdrawn  and  the  incision  closed,  usually 
with  a  suture.  A  generous  dressing  of  gauze  and  cotton 
pads  is  applied  under  a  binder  or  a  scultetus  bandage. 
These  will  require  to  be  changed  later,  as  some  leaking  is 
bound  to  continue. 

The  necessity  for  keeping  the  area  sterile  during  the 
entire  process  must  not  be  lost  sight  of;  some  care  will  be 
required  to  keep  the  patient  dry;  wet  towels  must  be  re- 
placed by  dry  ones. 

A  similar  operation  is  sometimes  used  to  remove  fluid 
from  the  lower  extremities  in  advanced  cases  of  dropsy. 
Small  perforated  silver  cannulse,  known  as  Southey's 
tubes,  with  fine  rubber  tubing  attached,  are  introduced 
at  different  points,  and  the  fluid  allowed  to  run  slowly 
away  into  a  convenient  receptacle.  Similar  aseptic  pre- 
cautions are  used. 

ASPIRATION 

Aspiration  is  a  method  of  tapping  which  precludes  all 
risk  of  introducing  air  into  the  cavity.  For  this  reason 
it  is  preferred  to  paracentesis,  as  described,  for  the  re- 


ASPIRATION 


531 


moval  of  fluid  fron  the  cavities  of  the  pleura  or  the 
pericardium. 

Usually,  as  a  preliminary  step,  the  presence  of  fluid 
is  first  ascertained,  and  its  nature  determined  by  a  pre- 
vious exploration,  as  already  described.  For  aspiration 
a  special  apparatus,  known  as  an  aspirator,  is  used  (Fig. 
167).  This  consists  of  a  large  glass  bottle  with  a  rubber 
cork,  into  which  fits  closely  a  two-armed  metal  tap;  each 


Fig.  164. — Aspiration  of  the  peritoneal  cavity.     First  step:  appli- 
cation of  the  abdominal  binder  (Morrow). 

arm  of  the  tap  is  provided  with  a  stop-cock;  to  each  arm  is 
connected  a  length  of  solid  rubber  tubing  (the  ordinary 
rubber  tubing  collapses  when  air  is  withdrawn).  The 
rubber  tubes  are  furnished  with  metal  connection  attach- 
ments at  either  end.  One  length  of  tubing  is  connected  to 
an  air-pump,  the  other  to  an  exploring  needle  or  a  trocar 
and  cannula.  By  the  air-pump  the  air  in  the  bottle  is 
exhausted,  thus  producing  a  vacuum;  when  the  exploring 


532      SURGICAL  TECHNIC   AND   MINOR   SURGICAL   EVENTS 

needle  is  introduced  into  the  cavity,  the  fluid  naturally 
escapes  into  the  vacuum. 

The  aspirator  should  always  be  tested  immediately 
before  being  prepared  for  use.  While  each  part  must  be 
carefully  cleaned  and  sterilized  after  use,  only  the  exploring 
needle  and  its  connecting  tube  should  be  resterilized  be- 
fore use,  as  the  sterilizing  process  is  very  apt  to  destroy 
the  absolute  adjustment  of  the  different  parts  on  which 


Fig.  165. — Aspiration  of  the  peritoneal  cavity.    Second  step:  nick- 
ing the  skin  at  the  point  of  puncture  (Morrow). 

the  proper  working  of  the  apparatus  depends.  This 
tube  should  be  in  two  parts,  connected  by  a  piece  of  glass 
tubing;  the  length  to  which  the  needle  is  attached  is  to 
be  kept  sterile  throughout,  and  should  be  of  a  convenient 
length,  so  that  the  aspirator  can  stand  on  a  table  securely 
out  of  the  way  of  the  clean  operator. 

The  needle  and  upper  part  of  the  tubing  are  usually 
sterilized  in  the  autoclave,  and  kept  until  required  in  the 
sterile  wrapper.  The  inside  of  the  bottle  is  kept  sterile, 


ASPIRATION 


533 


in  case  the  fluid  is  required  for  examination.  The  bottle, 
the  stop-cocks,  and  air-pump  are  managed  by  an  unsterile 
assistant,  or,  if  this  is  impracticable,  are  handled  with 
sterile  gauze.  The  air-pump  can  be  removed  when  the 
vacuum  is  formed. 

To  test  an  aspirator,  fill  a  bowl  with  sterile  water, 
adjust  the  parts,  and  open  the  stop-cock  connecting  with 
the  air-pump;  keep  the  other  closed;  work  the  pump  until 


Fig.  166. — Aspiration  of  the  peritoneal  cavity.     Third  step:  showing 
the  method  of  inserting  the  trocar  (Morrow) . 

stiff,  which  is  a  sign  that  the  air  is  exhausted.  Close  the 
stop-cock ;  place  the  needle  in  the  basin  of  water,  and  open 
the  stop-cock  connecting  it  with  the  bottle;  the  water 
should  run  into  the  bottle. 

If  the  apparatus  does  not  work  easily,  the  cause  must 
be  sought.  Part  of  the  apparatus  may  be  blocked  by 
coagulated  albumin  from  imperfect  cleansing;  usually 
the  fault  is  in  some  leakage  of  air  caused  by  drying  and 


534      SURGICAL  TECHNIC   AND   MINOR   SURGICAL   EVENTS 

shrinking  of  the  rubber  cork,  which  may  be  overcome 
by  soaking  the  cork  in  water. 

After  use,  the  greatest  care  should  be  taken  to  wash 
every  part  of  the  apparatus,  with  the  exception  of  the  air- 
pump,  immediately  under  running  cold  water  until  all 
organic  deposit  is  dissolved  and  removed. 

Besides  the  aspiration  apparatus,  the  usual  necessaries 
for  preparing  the  area,  towels,  gauze,  sponges,  hand 
lotion,  and  a  collodion  dressing  will  be  required. 

Some  surgeons  prefer  to  make  a  small  preliminary  in- 
cision with  a  scalpel  before  introducing  the  needle.  This 
is  no  bigger  than  a  puncture,  and  does  not  require  suturing. 


¥i 


Fig.  167. — Aspiration  of  the  pleura  (Morrow). 

Unless,  however,  a  nurse  is  perfectly  familiar  with  the 
methods  of  the  surgeon,  when  a  scalpel  is  ordered,  she 
should  prepare  against  emergencies,  needle,  silk  suture, 
artery  forceps,  and  catgut  ligature,  since,  with  our  modern 
methods,  these  cannot  be  got  ready  in  a  minute. 

In  watching  the  surgeon  introducing  an  aspirating  or 
exploring  needle,  you  may  frequently  notice  he  will  pull 
the  skin  a  little  upward  with  his  finger  before  beginning 
the  insertion.  By  doing  this  the  incision  in  the  skin  and 
the  incision  directly  into  the  viscera  are,  when  the  needle 
is  withdrawn,  not  exactly  opposite  each  other,  and  risk  of 
infection  through  the  skin  puncture  is  further  lessened. 

A  simple  puncture  is  closed  with  a  collodion  dressing; 


ASPIRATION  535 

if  the  incision  is  made  with  a  scalpel,  a  small  gauze  pad  is 
applied,  with  cross-strips  of  adhesive  plaster. 

For  aspiration,  the  hands  are  prepared  by  Formula  A; 
gown  and  gloves  are  worn. 

Aspiration  of  the  Chest-wall  (i.  e.,  the  Pleural  Cavity}.— 
A  collection  of  fluid  in  the  pleural  cavity  is  a  frequent 
accompaniment  of  disease  or  injury  to  the  lungs.  If 
the  fluid  is  found  on  exploration  to  be  purulent,  the  chest- 
wall  is  generally  opened  and  the  abscess  drained.  As 
a  means  of  temporary  relief,  and  in  conditions  where  non- 
purulent  fluid  is  largely  in  excess,  the  cavity  is  more  con- 
veniently emptied  by  aspiration. 

For  this  process  the  patient  lies  on  his  sound  side,  in  a 
semi-recumbent  position,  the  arm  of  the  affected  side 
raised  above  his  head,  and  the  shoulders  turned  forward. 
Pillows  arranged  under  the  side  of  the  chest  help  to  bulge 
the  ribs  over  the  affected  area. 

The  chest  is  prepared  from  the  spine  to  a  point  beyond 
the  axilla,  and  from  the  shoulder  to  the  waist.  The  needle 
is  usually  introduced  either  near  the  angle  of  the  shoulder- 
blade,  or  below  and  in  a  line  with  the  axilla. 

A  stimulant  should  always  be  in  readiness  for  this 
operation;  a  dose  of  whisky  is  frequently  ordered  as  a 
preliminary  precaution,  especially  if  a  local  anesthetic  is 
not  used. 

Coughing  during  the  operation  usually  signifies  that  the 
visceral  layer  of  the  pleura  has  been  pricked.  The  needle 
is  withdrawn,  or  the  lung  may  be  injured.  The  sputum 
should  be  watched  subsequently  for  traces  of  blood. 

Attacks  of  syncope,  sometimes  even  fatal,  are  not  un- 
common after  the  removal  of  a  large  quantity  of  fluid  from 
the  pleura,  due,  it  is  considered,  to  change  in  the  position  of 
the  thoracic  organs  caused  by  the  emptying  of  the  sac.  Pa- 
tients should  be  cautioned  to  lie  still  and  to  make  no  sudden 
movement  or  attempt  to  sit  up  for  twenty-four  hours  after 
the  operation.  The  pulse  should  be  carefully  watched. 

Aspiration  of  the  Pericardium. — The  operation  does  not 
differ  in  any  essential  from  that  of  aspiration  of  the  pleura. 
In  cardiac  disorders  the  patient  is  frequently  compelled 
to  keep  the  upright  position,  and  in  all  circumstances  the 


536      SURGICAL   TECHNIC  AND   MINOR   SURGICAL   EVENTS 

position  in  which  he  can  breathe  most  easily  must  be 
preferred.  The  needle  is  introduced  at  a  point  near  the 
left  margin  of  the  sternum,  generally  between  the  fourth 
and  fifth  rib.  This  point  may  be  taken  as  the  center  of 
the  area  to  be  prepared.  If  the  chest  is  very  hairy, 
shaving  is  necessary,  but  usually  the  process  is  shortened 
as  much  as  possible  in  order  to  make  no  demands  on 
the  patient's  strength.  A  stimulant,  preferably  whisky, 
should  be  prepared,  but  in  this  case  is  generally  given  after, 
rather  than  before,  the  operation.  Local  anesthesia  is 
not  usually  ordered. 

The  condition  of  the  patient  makes  aspiration  of  the 
pericardium  always  an  important  process.  He  must  be 
closely  watched  throughout  and  subsequently  for  signs  of 
syncope,  such  as  changes  in  the  pulse-rate,  pallor,  yawning 
and  sighing,  or  coughing.  Many  doctors  order  the  hy- 
podermoclysis  apparatus  in  readiness  before  beginning  the 
operation.  Where  the  exploring  needle  has  shown  the 
fluid  to  be  purulent,  the  more  usual  operation  is  the  open- 
ing of  the  pericardium,  in  order  to  drain  the  abscess. 

Nurses  cannot  be  too  carefully  impressed  with  the 
necessity  for  strict  aseptic  precautions,  both  in  preparing 
for  any  of  the  above  surgical  proceedings  and  during 
the  operation.  Small  though  the  puncture  of  an  exploring 
needle  or  cannula  may  be,  it  is  sufficient  to  form  a  channel 
of  infection  to  these  important  organs. 


THE  OPERATING-ROOM 

Equipment — Duties — Operations  in  Private  Work. 

A  PUPIL  that  has  been  carefully  taught  practical  asepsis, 
and  has  intelligently  grasped  the  principles  on  which  sur- 
gical technic  is  based,  will  find  no  insurmountable  diffi- 
culties in  learning  her  duties  in  the  operating-room. 
Still,  the  operating-room  is  a  region  in  which  emergencies 
constantly  arise,  in  which  action  must  follow  judgment 
promptly,  and  in  which  a  clear  head,  self-control,  and 
alertness  are  essential  qualifications  if  confusion  is  to  be 
avoided. 

No  pains  should  be  spared  to  make  each  nurse  perfectly 
familiar  with  each  instrument  or  appliance  used,  with 
the  purpose  of  all  articles  in  the  equipment,  and  to  teach 
her  the  proper  way  to  hold  a  limb,  apply  and  control  a 
tourniquet,  or  to  perform  any  one  of  the  services  she  may 
suddenly  be  called  upon  to  give.  An  emergency  is  ob- 
viously not  the  time  for  instruction. 

EQUIPMENT  OF  THE  OPERATING-ROOM 

The  tendency  of  modern  surgery  is  toward  simplicity 
of  equipment,  and  the  rule  in  a  modern  operating-room  is 
to  have  nothing  but  what  is  strictly  necessary  for  the  work 
in  hand. 

The  furniture  preferred  at  the  present  day  is  made  of 
white  enamel,  iron,  and  glass,  which  presents  a  non-ab- 
sorbent surface  and  is  easily  cleaned  and  disinfected.  All 
vessels  used,  bowls,  trays,  etc.,  are  also  either  of  glass  or 
of  enamelware. 

The  movable  equipment  consists  of  the  operating-table, 
a  convenient  number  of  glass  tables,  and  a  couple  of  chairs 
or  stools,  usually  in  enameled  iron.  Of  these  latter,  one 
is  required  for  the  anesthetist,  and  one  for  certain  opera- 
tions, such  as  on  the  perineum,  at  which,  as  a  rule,  the 

537 


538 


THE    OPERATING-ROOM 


operator  sits.     The  tables  are  provided  with  large  rubber 
castors  or  with  slides,  in  order  that  they  can  readily  be 


moved  without  lifting.  A  "  clean  "  person,  for  example, 
can  move  such  a  table  into  position  with  the  foot  and  so 
avoid  breaking  technic. 

The  operating-table  in  general  use  is  also  made  of  white 
enameled  iron  and  glass,  and  so  constructed  that  it  can 
be  shortened  or  extended  and  the  angle  changed  while 
the  patient  is  in  place.  The  nurses  should  be  familiar  with 


EQUIPMENT   OF   THE    OPERATING-ROOM 


539 


the  simple  mechanism  by  which  the  changes  are  made. 
The  glass  is  arranged  on  the  iron  framework  in  panels 
sloping  toward  the  center  of  the  table,  and  with  openings 
between  the  panels;  by  this  arrangement  fluids  run  off  the 
table  into  a  trough  underneath,  and  so  keep  the  surface 
comparatively  dry. 


Fig.  169.— Boldt's  hospital  examining  and  operating-table,  showing 
an  adjustable  stirrup  with  strap  and  a  heel  stirrup  (Ashton). 

A  special  bracket  table  of  similar  make  may  be  attached 
to  the  table  for  operations  on  an  extremity. 

The  angle  of  the  table  is  altered  by  means  of  a  cog- 
wheel, turned  by  a  detachable  handle.  By  this  means 
the  Trendelenburg  position  can  be  assumed  (Fig.  51),  and 
the  height  adjusted  without  disarranging  the  operation. 
In  doing  this  while  an  operation  is  in  progress  care  must 


540  THE   OPERATING-ROOM 

be  taken  to  work  under  the  sterile  coverings,  or  the  technic 
will  be  broken. 

About  one-third  from  the  lower  end  the  lower  panels  can 
be  folded  down,  in  order  to  shorten  the  table.  At  this 
point  are  a  pair  of  metal  holders,  one  on  each  side,  into 
which  the  "  crutches  "  are  fitted  when  required,  and  held 
in  place  by  a  screw. 

The  crutches  are  a  pair  of  long  metal  rods  from  which 
are  suspended  "  stirrups,"  usually  made  of  broad  webbing 
(Fig.  169).  Their  object  is  to  keep  the  lower  extremities 
raised  and  separated,  as  in  the  lithotomy  position.  The 
feet  rest  in  the  webbing  stirrups.  When  in  place,  the 
"  crutches  "  should  be  at  such  a  height  that,  with  the  feet 
in  the  stirrup,  the  knees  are  well  flexed  and  separated. 

The  crutches  are  used  for  operations  on  the  perineum, 
rectum,  vagina,  and  adjacent  parts. 

Near  the  head  of  the  table  are  a  pair  of  shoulder  sup- 
ports, for  use  if  the  patient  is  put  in  the  Trendelenburg 
position.  These  should  not  be  used  unnecessarily,  as  the 
prolonged  pressure  involved  is  quite  apt  to  cause  edema  of 
the  arm,  numbness,  and  even  temporary  paralysis. 

Pillows  or  pads  of  some  sort  are  necessary  to  keep  the 
patient  from  resting  entirely  on  the  hard  table.  These 
should  be  adjusted  with  care,  as  bruising  of  the  coccyx 
from  long  pressure  on  the  glass  of  the  operating  table  is, 
not  uncommonly,  the  starting-point  of  a  bed-sore. 

If  pads  are  preferred,  they  should  be  two  in  number, 
placed  lengthwise  on  the  middle  division  of  the  table,  and 
should  not  meet  in  the  center  or  they  will  prevent  the 
fluids  draining  from  the  table.  They  should  be  flat, 
stuffed  with  hair,  and  covered  with  rubber  sheeting; 
they  should  not  be  larger  than  the  panels  they  are  to  cover, 
or  they  will  be  in  the  way  if  the  table  is  to  be  shortened. 

Some  hospitals  use  a  folded  blanket  as  a  pad.  The 
blanket  is  covered  first  with  a  rubber  sheet,  and  above  the 
rubber  a  cotton  sheet,  both  tucked  smoothly  under  the 
blanket.  This  makes  an  excellent  pad  for  private  work, 
but  has  the  disadvantage  of  preventing  the  fluids  from 
draining  away,  and  in  many  operations  keeps  the  back 
lying  in  a  puddle. 


EQUIPMENT   OF  THE   OPERATING-ROOM  541 

A  common  practice  is  to  use  small  hair  pillows,  covered 
in  rubber  sheeting,  adjusted  so  as  to  keep  bony  prominences 
off  the  table.  The  usual  requirement  is  one  for  the  head, 
one  under  the  shoulders,  and  one  under  the  coccyx. 
Pads  or  pillows  should  be  covered  with  cotton  slips  when 
in  use,  as  rubber  in  contact  with  the  skin  makes  it  hot  and 
moist,  and  favors  the  formation  of  bed-sores. 

After  use  every  part  of  the  table  is  scrubbed  with  soap 
and  water,  and  when  clean,  usually  wiped  with  an  anti- 
septic, either  carbolic  1  : 20  or  formalin  2  per  cent.  In 
many  hospitals  the  operating-table  and  the  sterile  tables 
are  wiped  with  an  antiseptic  again  before  use.  This  is 
not  actually  necessary,  since  they  are  entirely  covered 
by  the  sterile  coverings  during  the  operation. 

The  other  tables  considered  necessary  vary  somewhat 
in  different  operating-rooms.  One  or  two,  according  to 
the  assistants  available,  are  covered  with  sterile  towels  and 
kept  "  sterile "  throughout.  On  these  are  placed  the 
instruments,  sutures,  sponges,  dressings,  and  all  sterile 
appliances.  Some  surgeons  use  a  narrow  instrument 
table  placed  across  the  operating-table  at  a  convenient 
height;  in  most  cases  an  ordinary  glass  table  is  used,  placed 
beside  the  assistant  who  is  to  hand  the  instruments. 

Besides  the  sterile  tables,  one  table  is  required  for  the 
anesthetist,  one  should  be  kept  set  out  with  the  usual  re- 
quirements for  emergencies,  and  a  third  will  be  required 
for  other  articles  to  be  handled  by  the  unsterile  nurse. 

The  anesthetist's  table,  which  is  placed  at  the  head  of 
the  operating-table,  should  contain  the  following,  all 
arranged  conveniently : 

The  anesthetic  to  be  used,  as — 

a.  Ether  and  ether  cone. 

b.  Chloroform  in  drop  bottle  and  chloroform  mask. 

c.  Tube  of  ethyl  chlorid  and  square  of  folded  gauze. 
Tongue  forceps. 

Sponge  holder. 

Mouth-gag. 

Gauze  sponges. 

Small  towels. 

Small  jar  of  sterile  vaselin. 

Small  jar  of  boric  solution,  2  per  cent.,  with  eye-dropper. 


542  THE   OPERATING-ROOM 

Local  anesthetics,  such  as  Schleich's  solution,  cocain, 
eucain,  etc.,  if  required,  should  be  ready  in  the  hypodermic 
syringe  in  the  dose  ordered,  or  if  required  for  an  eye,  in  a 
small  sterile  bottle  with  the  eye-dropper. 

The  tongue  forceps  are  used  to  pull  the  tongue  forward 
if  it  should  drop  to  the  back  of  the  throat,  especially  in 
operations  where  the  head  cannot  be  turned  to  the  side. 
The  sponge-holder,  with  small  gauze  sponge,  is  to  clear  the 
throat  of  accumulations  of  mucus;  vaselin  is  used  to  smear 
the  lips,  nose,  and  chin  in  giving  chloroform,  as  if  chloro- 
form is  dropped  on  the  skin  a  burn  will  be  produced; 
if  the  same  accident  happens  to  the  eye,  it  is  immediately 
irrigated  with  the  boric-acid  solution. 

On  the  emergency  table  are  placed  the  following: 

Hypodermoclysis  apparatus. 

Normal  salt  solution  flasks,  both  hot  and  cold. 

Hypodermic  tray. 

Enema  tube,  funnel,  and  pitcher,  with  small  bottle  of 
whisky  or  brandy. 

The  oxygen  apparatus  stands  beside  the  table. 

The  hypodermic  tray  should  contain  the  hypodermic 
tablets  most  frequently  required  (atropin,  strychnin, 
nitroglycerin,  morphin,  and  cocain),  two  syringes  ready 
charged,  one  with  strychnin  (-jV  to  yV  grain)  and  one  with 
atropin  (yi^  to  yitr  grain),  wrapped,  until  required,  in  a 
piece  of  gauze  soaked  in  alcohol,  a  small  flask  of  sterile 
water,  a  small  bottle  of  alcohol,  and  a  jar  of  sterile  gauze 
sponges. 

It  is  always  a  good  plan  that  this  table  should  be  pre- 
pared as  a  matter  of  routine,  if  only  because  it  familiarizes 
the  pupils  thoroughly  with  what  is  required  in  cases  of 
emergency. 

Reserve  Table. — On  a  table,  conveniently  on  one  side, 
are  placed  reserve  packets  of  sponges,  towels,  dressings, 
gloves,  and  gowns,  to  be  unpinned  and  passed  to  the 
clean  nurses  or  assistants,  as  required.  On  this  table  will 
also  be  placed  bandages,  pins,  adhesive  strapping,  appli- 
ances, such  as  splints,  tourniquets,  extra  pillows  or  sand- 
bags, if  likely  to  be  required;  dusting-powders,  iodoform 
emulsion,  and  similar  articles  not  constantly  used.  A 


EQUIPMENT   OF  THE   OPERAT1XG-ROOM  543 

small  tray  with  the  necessaries  for  taking  cultures  (p.  406) 
should  also  always  be  in  readiness,  and  may  conveniently 
be  kept  on  this  table. 

In  some  hospitals  it  is  a  routine  practice  to  wash  out 
the  stomach  after  prolonged  anesthesia,  especially  in 
abdominal  operations.  A  large  pitcher,  a  deep  basin,  and 
the  stomach-tube  and  funnel  should  be  prepared,  together 
with  any  drug  that  may  be  ordered.  Castor-oil  (1  to  2 
ounces)  is  frequently  left  in  the  stomach  after  the  lavage. 

Extra  flasks  of  normal  salt  solution  and  of  sterile  soap, 
ether,  and  alcohol,  and  covered  glass  jars  containing 
sterile  sutures,  ligatures,  drains,  and  tubing,  are  con- 
veniently kept  on  glass  shelves  or  stands,  either  in  the 
operating-room  or  close  at  hand. 

Preparation  Table. — It  is  often  a  convenience  to  arrange 
a  separate  table  with  the  necessaries  for  the  preparation  of 
the  area  of  operation.  On  it  are  placed  flasks  of  soap, 
alcohol,  ether,  and  the  antiseptic  solution  used,  sterile 
basin  and  brush  in  wrapper,  packet  of  sponges,  packet 
of  towels,  razor,  a  pair  of  bandage  scissors,  and  two 
pieces  of  rubber  sheeting.  For  a  vaginal  preparation  long 
sponge-holders  and  small  sponges  are  added. 

Cupboards,  Stands,  etc. — A  closet  at  hand  should  con- 
tain a  supply  of  blankets,  ether  hose  and  gown,  pillows, 
pillow-slips,  and  hot-water  bags.  During  an  operation 
some  blankets  and  a  set  of  hose  and  gown  should  be  kept 
on  the  steam-pipes  or  other  hot  place,  as  the  patient  should 
be  returned  to  bed  in  warm,  dry  clothing. 

The  instrument  cupboard,  usually  also  at  the  present 
day  made  of  glass,  with  a  metal  framework,  should  be 
arranged  conveniently,  instruments  of  one  kind  arranged 
together  in  orderly  rows.  No  instrument  wanting  repair, 
and  no  old-fashioned  instrument  not  commonly  in  use, 
should  be  kept  in  the  instrument  cupboard. 

Separate  stands,  each  to  hold  one  large  basin,  are  gener- 
ally used  for  hand  lotion  or  sterile  water,  as  preferred. 
One  is  placed  near  the  operator,  and  one  by  the  sterile 
nurse  or  assistant.  In  some  hospitals  iron  rings  take  the 
place  of  the  basin  stands,  and  are  fitted  into  sockets  on 
the  sterile  stands  or  on  the  walls  If  desirable,  these 


544  THE    OPERATING-ROOM 

rings  may  be  sterilized  with  the  basins,  and  the  whole  then 
handled  by  the  sterile  nurse. 

Sponge  Receptacle. — A  special  receptacle  is  kept  for 
used  sponges  only.  This  may  be  a  wire  basket,  slop 
bucket,  etc.  Some  hospitals  use  a  large  bag  of  stout 
muslin  tied  to  the  four  corners  of  the  frame  of  a  glass 
table  or  stand  in  place  of  the  glass  slab,  by  which  means 
the  bag  is  held  conveniently  wide  open. 

The  wash-stands,  whether  in  the  dressing-rooms  or 
operating-room,  should  be  provided  with  liquid  soap, 
sterile  brushes,  orange-wood  sticks,  and  nail-files,  one 
set  to  each  basin.  These  are  usually  kept  standing 
during  the  operation  in  an  antiseptic  solution— carbolic, 
1  :  20,  or  bichlorid,  1  :  1000.  A  fresh  set  of  brushes,  etc., 
is  put  out  for  each  operation.  At  hand  are  basins  contain- 
ing the  lotion  according  to  the  formula  used  in  preparing 
the  hands. 

Basins  and  Pitchers. — A  sufficient  supply  of  sterile 
basins,  pitchers,  and  small  bowls  must  be  in  readiness. 
According  to  the  method  by  which  they  are  sterilized  these 
will  be  in  cotton  wrappers,  or  taken  when  required  from  the 
sterilizer  in  which  they  are  boiled.  A  large  sterilizer  in 
which  a  number  of  vessels  can  be  boiled  at  one  time  and 
kept  until  wanted  is  a  great  saving  of  time  in  an  operating- 
room. 

Water-supply. — All  modern  operating-rooms  are  pro- 
vided with  a  generous  supply  of  sterile  water;  generally 
the  necessary  sterilizers  are  placed  near  the  operating- 
room,  and  in  charge  of  the  operating-room  nurse.  Care 
must  be  taken  to  keep  a  sufficient  amount  sterilized  for 
all  demands. 

In  many  hospitals  of  quite  modern  construction  all 
the  water  laid  on  in  the  pipes  of  the  operating-room  is 
actually  sterile,  and  can  be  used  for  ordinary  purposes 
(solutions,  skin  preparation,  and  so  forth)  directly  from 
the  taps.  Normal  salt  solution,  to  be  used  for  hypodermo- 
clysis  or  irrigation  of  closed  cavities,  must  be  further 
sterilized  in  the  autoclave  or  by  the  fractional  method. 

We  saw  in  the  last  chapter  that  surgical  technic,  as  we 
understand  it  to-day,  usually  calls  for  two  pairs  of  hands, 


EQUIPMENT   OF   THE    OPERATING-ROOM  545 

"  clean "  and  "  unsterile,"  thus  doubling  labor.  In 
modern  operating-rooms  many  devices  have  been  intro- 
duced to  obviate  this  necessity  to  a  great  extent. 

Foot-pedals  are  used  to  turn  on  the  water  in  wash- 
basins, etc.,  thus  doing  away  with  any  need  for  touching 
taps.  The  water  sterilizer  may  also  be  fitted  in  the  same 
way.  Large  sterile  glass  jars  are  provided  for  the  lotions, 
fitted  with  stop-cocks  also  worked  by  foot-pedals;  these 
are  placed  on  a  glass  bracket  of  suitable  height.  By  these 
arrangements  the  sterile  nurse  can  draw  water  and  pre- 
pare the  lotions  without  coming  in  contact  with  an  un- 
sterile  object. 

Where  the  dressings,  etc.,  are  put  up  in  packets  (or 
jars  or  tubes,  etc.),  an  unsterile  assistant  is  required  to 
open  the  packets.  In  place  of  the  packets  large  metal 
drums  are  provided,  into  which  the  dressings,  etc.,  are 
packed  and  sterilized  without  the  need  for  separate 
wrappings.  The  drums  are  placed  on  special  stands  in 
the  operating-room,  furnished  with  foot-pedals  by  which 
the  lids  of  the  drums  are  raised. 

Generally,  three  drums  are  provided:  one  for  the  gowns, 
caps,  and  gloves,  hand-brushes  and  nail-cleaners,  and  the 
covers  for  sterile  stands;  a  second  for  sterile  towels;  and 
the  third  for  dressings,  including  sponges,  tubes  of  pack- 
ing, etc.,  sufficient  for  a  full  day's  operating.  The  sponges 
and  dressings  are  tied  with  tape  into  bundles  of  a  given 
number.  A  fourth  drum  is  often  provided,  fitted  with  an 
electric  heater  in  which  towels  and  gauze  pads  to  be  used 
in  walling  off  the  viscera  in  certain  operations  can  be 
kept  sterile  and  hot,  thus  doing  away  with  the  need  of 
wringing  them  out  in  boiling  water. 

From  these  drums  the  sterile  nurse  can  help  herself 
without  assistance  or  risk  of  breaking  her  technic. 

A  large  boiler  in  which  all  the  basins,  pitchers,  etc.,  to 
be  used  are  sterilized  may  be  provided  in  the  same  way 
with  a  foot-pedal  for  raising  the  lid. 

There  remain  only  the  jars  in  which  sutures  are  stored, 

and  the  small  flasks  of  soap,  ether,  and  alcohol  to  be  used 

in  the  skin  preparation.     These  are  tightly  corked  with 

ground-glass  stoppers,  and  are  immersed  in  a  disinfectant 

35 


546  THE    OPERATING-ROOM 

(formalin,  2  per  cent. ;  bichlorid  of  mercury,  1  : 1000,  etc.) 
for  at  least  one  hour  before  they  are  to  be  used.  A  glass 
graduate,  to  be  used  in  measuring  the  solutions,  is  prepared 
with  these  bottles.  In  an  operating-room  fitted  in  this 
way  one  "  sterile  "  nurse  can  set  out  the  entire  operating- 
room  for  whatever  number  of  operations,  in  a  very  short 
time,  without  requiring  the  help  of  an  unsterile  assistant, 
as  she  must  do  if  packets,  etc.,  are  to  be  opened. 

Mops. — The  last  item  of  equipment  to  be  remembered  is 
a  mop,  with  which,  from  time  to  time,  to  wipe  up  the  floor 
and  keep  it  from  getting  greasy  and  slippery.  This 
should  stand  on  one  side,  in  a  bucket  of  disinfectant,  usually 
carbolic  1  : 20.  After  use  it  must  be  well  washed  in  hot 
soap  and  water  and  dried  in  the  open  air  and  resterilized. 

Gowns. — A  special  uniform  is  usually  required  in  the 
operating-rooms.  The  nurse's  consists  of  a  skirt  and  loose, 
short-sleeved  blouse  of  unbleached  muslin.  The  skirt  is 
short — about  four  inches  from  the  ground.  For  the  doc- 
tors a  loose,  short-sleeved  shirt  and  trousers  of  the  pajama 
shape  in  the  same  material  are  provided.  These  uniforms 
are  clean,  but  not  sterile.  Over  these  uniforms,  during 
the  operation,  is  worn  the  usual  sterile  gown.  The  gown 
is  not  put  on  until  after  the  hands  are  scrubbed  up. 
Most  of  these  gowns  are  made  with  long  sleeves,  which, 
at  the  wrist,  are  tucked  inside  the  cuff  of  the  rubber  glove. 
The  hair  is  also  covered  with  a  sterile  cap.  The  operator 
and  his  assistants  also  frequently  wear  sterile  gauze 
masks  during  the  operation,  and  have  the  beard  tied  up  in 
sterile  gauze.  If  this  is  not  done,  it  is  the  duty  of  an  "un- 
sterile "  nurse  to  wipe  the  faces  free  from  perspiration  from 
time  to  time  with  a  sterile  towel. 

Patient's  Dress. — In  most  hospitals  a  special  dress  is 
provided  for  the  patient  during  operations.  This  usually 
consists  of  jacket  and  hose  of  Canton  flannel  or  other  warm 
washable  material.  The  jacket  should  be  roomy  and 
long  enough  to  reach  below  the  hips;  it  is  fastened  behind 
with  a  single  button  at  the  neck.  The  hose  are  made  like 
loose,  roomy  stockings,  and  reach  to  the  hip.  Jacket  and 
hose  are  kept  on  during  the  operation,  unless  they  are  in 
the  way  of  the  part  to  be  operated  on. 


DUTIES  OF  THE  NURSES  547 

The  linen  supply  necessary  for  each  operating-room  in- 
cludes the  following: 

Doctors'  suits,  gowns,  and  caps.  \  In  heavy  unbleached 

Nurses'  dresses,  gowns,  and  caps,  j      muslin. 

Sheets  for  the  operating-table. 

Pillow-slips. 

Towels  (dressing,  used  sterile). 

Hand-towels. 

Wrappers  for  sterile  dressings,  etc.  (double  fold  of  un- 
bleached muslin). 

Ether  jackets  and  hose. 

The  stock  cupboard  should  also  contain  hot-water 
bags  with  washable  covers;  rubber  bathing  caps,  to  pro- 
tect the  patient's  hair  in  operations  about  the  face,  etc.; 
rubber  bandages;  tourniquets;  and  various  pillows  of 
different  shapes  and  sizes,  some  stuffed  with  hair  and 
others  filled  with  sand.  These  are  required  in  keeping  a 
patient  in  a  fixed  position  during  an  operation ;  they  should 
be  covered  in  rubber  sheeting.  Pillows  of  bolster  shape, 
about  18  inches  long,  firmly  stuffed  with  hair,  are  conven- 
ient to  place  under  a  patient  lying  on  his  side  in  certain 
operations,  such  as  on  the  kidney  or  on  the  spine.  To 
these  may  be  added  the  foot-rest  and  pelvic  rest  described 
in  the  chapter  on  Bandaging.  A  hot  closet  in  which 
blankets  can  be  kept  is  a  helpful  addition  to  the  operating 
equipment. 

DUTIES   OF  THE  NURSES 

It  is  not  possible  to  lay  down  any  fixed  rules  as  to  the 
duties  of  the  nurses  in  an  operating-room:  they  vary  with 
the  number  of  assistants  and  with  the  facilities  of  equip- 
ment. The  minimum  assistance  required  at  an  operation 
under  aseptic  methods  is  one  "  clean  "  assistant  and  one 
unsterile;  this  does  not  include  the  anesthetist.  In  a 
hospital  operating-room  three  nurses  is  often  a  practical 
number,  a  head  nurse  permanently  in  charge,  and  two 
pupils.  During  the  operation  one  pupil,  or  both  if  required, 
remains  clean.  It  is  usually  best  that  the  head  nurse 
remains  free  to  supervise  and  direct  the  pupils,  to  see 
that  everything  required  for  the  succeeding  operations 


548  THE   OPERATING-ROOM 

is  prepared  in  time,  and  to  keep  watch  that  no  one  breaks 
the  technic.  In  small  hospitals,  however,  she  may  be 
the  only  one  actually  attached  to  the  operating-room,  and 
frequently  called  upon  by  the  operator  to  act  as  a  second 
surgical  assistant  in  minor  details,  such  as  sponging, 
holding  the  retractors,  etc.  In  these  circumstances  the 
charge  nurse  should  be  "  clean,"  as  she  must  accustom 
herself  to  the  methods  of  the  different  surgeons,  who  must 
also  feel  that  she  can  be  relied  on  to  understand  what  is 
required — a  confidence  naturally  not  extended  to  the 
transient  pupil.  In  order  to  get  the  necessary  training, 
the  pupils  in  turn  must  also  act  as  "  clean  "  nurses  and 
help  her  in  her  duties. 

The  clean  nurse  usually  has  charge  of  the  sponges, 
towels,  dressings,  ligatures,  sutures,  and  needles.  These 
she  arranges  after  she  is  clean,  on  a  table  previously  cov- 
ered by  a  sterile  towel,  taking  them  from  the  packets, 
jars,  etc.,  opened  by  the  unsterile  nurse.  The  instruments 
may  be  in  her  charge  also,  arranged  in  a  convenient  row 
on  her  table,  and  handed  by  her  as  required.  The  in- 
struments are  brought  to  her  by  the  unsterile  nurse  in  the 
tray  in  which  they  are  sterilized.  If  two  nurses  are 
clean,  the  junior  may  be  given  the  sponges  and  dressings 
as  her  care,  and  the  senior  the  instruments,  ligatures, 
sutures,  and  needles. 

The  instruments  are  often  regarded  by  nurses  as  a 
special  bugbear,  and  much  needless  anxiety  is  caused  by 
leaving  the  pupils  vague  as  to  the  uses  of  the  different 
instruments  and  the  special  requirements  of  the  different 
operations. 

In  hospital  work  the  operating-room  staff  should  be 
provided  with  a  book  in  which  the  instruments,  special 
needles,  and  the  kind  of  sutures  required  for  each  kind  of 
operation  are  clearly  listed.  At  the  same  time  the  charge 
nurse  should  go  over  the  instruments  in  the  instrument 
closet  with  each  pupil,  grouping  those  required  for  special 
work  together.  Many  instruments  are  called  by  special 
names,  usually  after  a  surgeon  who  has  added  some  im- 
provement to  the  instrument.  With  these  also  the  pupil 
must  be  familiar,  as  there  is  nothing  in  the  name  to  suggest 


DUTIES   OF  THE    NURSES  549 

whether  the  instrument  may  be  a  needle-holder,  a  retrac- 
tor, or  something  widely  different,  and  she  finds  herself 
at  a  loss  if  it  is  asked  for  by  its  special  name. 

The  Clean  Nurse. — The  routine  duties  of  the  clean  nurse 
(or  nurses')  consist  in  passing  the  sterile  objects  mentioned 
as  required,  and  in  keeping  the  sterile  area  surrounded 
with  sterile  towels.  She  must  keep  close  watch  that  she 
touches  nothing  unsterile. 

She  may  be  called  upon,  where  there  is  not  much  assist- 
ance, to  prepare  the  area  of  operation.  This  she  usually 
does  after  she  has  prepared  her  hands  by  formula, 
but  before  putting  on  her  gown  and  gloves.  After  the 
preparation  she  again  sterilizes  her  hands  and  puts  on 
her  gown  and  gloves,  while  the  assistant  operator  repeats 
the  disinfecting  part  of  the  preparation.  Since  the  area 
has  already  been  prepared  in  the  ward,  everything  used 
in  the  process — brush,  basin,  etc. — must  be  sterile,  and 
the  surrounding  parts  covered  with  sterile  towels. 

If  there  has  been  no  previous  preparation,  the  patient 
is  shaved  and  the  whole  process  completely  carried  out 
once  by  an  unsterile  assistant  or  nurse  before  it  is  touched 
by  any  one  clean.  Otherwise  the  duty  of  the  unsterile 
nurse  is  to  remove  the  bandage  and  protective  dressing, 
and  pour  the  soap,  alcohol,  etc.,  from  the  flasks  when 
required. 

During  the  preparation  rubber  sheets  are  placed  one 
above  and  one  below  the  site  of  operation,  to  protect 
the  coverings,  and  are  removed  when  this  is  complete. 

The  Sheet. — The  preparation  complete,  the  clean  nurse 
arranges  the  sterile  coverings.  During  the  operation 
patient  and  table  are  covered  with  a  sterile  "  operation  " 
sheet.  A  proper  operation  sheet  is  cut  one  yard  longer 
than  the  table  and  one  yard  wider;  three-quarters  of  a  yard 
from  one  end  an  opening  is  fashioned,  either  square  or  oval, 
usually  eight  inches  long  by  six  wide.  The  sheet  is 
arranged  so  that  the  opening  comes  exactly  over  the  site 
of  the  operation.  Practically  the  operation  sheet  is  found 
inconvenient  if  the  table  has  to  be  rearranged  during  an 
operation.  Usually  a  large  sheet  to  cover  the  lower  half  of 
the  table  and  patient,  and  a  smaller  sheet  laid  across  the 


550  THE   OPERATING-ROOM 

upper  part  of  the  patient's  body,  is  found  a  more  convenient 
arrangement. 

The  sheets  must  be  adjusted  to  suit  the  operation. 
For  example,  for  an  abdominal  section  the  upper  margin 
of  the  lower  sheet  is  turned  over  and  under  the  edge  of 
the  covering  blanket  at  the  pubes,  and  the  lower  margin 
of  the  upper  sheet  in  the  same  manner  over  and  under  the 
patient's  upper  garment,  about  the  tip  of  the  sternum. 
The  immediate  sterile  area  is  arranged  above  the  sheets; 
usually  it  is  made  with  four  sterile  towels  arranged  sym- 
metrically round  the  site  of  the  incision.  To  prevent 
the  towels  slipping  they  are  either  pinned  together  or  held 
together  with  clips;  the  towels  are  changed  from  time  to 
time  during  an  operation  by  the  sterile  nurse. 

The  sterile  area  in  operations  on  the  vagina,  perineum, 
rectum,  etc.,  with  the  patient  in  the  lithotomy  position, 
is  a  little  more  difficult  to  arrange.  A  Kelly  pad  is  placed 
under  the  pelvis,  and  over  it  a  sterile  sheet  covering  the 
lower  end  of  the  table,  and  gathered  into  a  sterile  bucket 
on  the  floor;  each  extremity  is  wrapped  in  a  sterile  sheet,and 
and  a  corner  of  each  brought  over  and  pinned  together 
above  the  pubes;  a  fourth  sheet  covers  the  patient  and 
table  above,  overlapping  the  side  sheets  at  the  pubes  and 
thighs.  The  immediate  area  is  covered  by  four  sterile 
towels  previously  pinned  together  to  leave  the  necessary 
opening.  The  clean  nurse  should  keep  one  or  two  reserve 
sets  of  towels  pinned  in  readiness,  as  it  is  difficult  to  adjust 
them  separately  in  this  position  without  slipping. 

If  a  nurse  has  to  remain  clean  for  a  second  operation,  her 
duties  end  when  she  passes  the  sterile  dressings.  The 
dressings  are  kept  in  their  wrappers  until  actually  required. 
If  the  case  has  not  been  perfectly  clean  throughout,  she  is 
required  to  change  her  gown  and  gloves  and  prepare  her 
hands  again  by  formula.  Otherwise  she  stands  aside  and 
waits  until  the  unsterile  nurse  brings  her  the  fresh  packets 
of  towels,  sponges,  etc.,  and  the  instruments  for  the  next 
operation.  In  an  active  operating-room  the  tables  are, 
for  the  different  operations,  usually  prepared  beforehand, 
and  brought  into  the  operating-room  with  the  fresh 
case.  If  possible,  the  pupils  should  then  act  as  clean 


DUTIES   OF   THE   NURSES  551 

nurse  in  turns,  thus  avoiding  delay  and  also  mitigating 
the  fatigue. 

The  Unsterile  Nurse. — On  the  unsterile  nurse  devolves 
the  placing  of  the  patient  in  the  required  position  on  the 
table,  the  adjustment  of  the  table  at  the  proper  angle,  and 
the  arrangement  of  the  unsterile  coverings. 

Position  of  Patient. — The  patient  is  usually  fully  anes- 
thetized when  brought  into  the  operating-room.  In 
placing  him  on  the  table,  the  nurse  must  take  particular 
care  to  adjust  the  pads  or  pillows  so  as  to  protect  bony 
prominences  from  contact  with  the  hard  surface  of  the 
table,  or  the  prolonged  pressure  involved  may  be  the 
starting-point  of  a  bed-sore. 

The  usual  position  of  a  patient  under  ether  is  on  the 
back,  the  body  fully  extended,  and  the  head  turned  to  one 
side.  The  body,  except  the  part  to  be  exposed,  is  covered 
with  a  woolen  blanket  well  tucked  in  round  the  lower 
limbs.  A  single  light  blanket  may  be  thrown  across  the 
chest — generally  the  ether  jacket  is  sufficient  covering. 
The  jacket  should  be  unbuttoned  at  the  neck  before  the 
anesthetic  is  begun.  The  ether  hose  are  kept  on,  except 
when  a  lower  limb  is  to  be  operated  on. 

The  Patient's  Arms. — Different  methods  are  employed 
for  keeping  the  arms  at  rest  and  out  of  the  way,  especially 
in  operations  on  the  abdomen.  Many  cross  the  arms  on 
the  chest  and  fix  them  by  turning  the  lower  margin  of  the 
jacket  over  the  arms  and  tucking  the  ends  firmly  under 
the  body.  Others  consider  that  the  arms  crossed  on  the 
chest  impede,  to  some  extent,  the  breathing,  and  keep 
the  arms  extended  on  either  side.  As  the  table  is  narrow,  it 
is  necessary  to  fix  the  arms,  or  a  slight  movement  may  cause 
them  to  roll  over  the  side  of  the  table  and  perhaps  be 
injured. 

One  method  is  as  follows: 

Lay  a  draw-sheet  across  the  table,  so  that  it  will  lie 
under  the  patient's  body,  reaching  from  the  axilla  to  the 
hips;  the  arms,  fully  extended,  are  laid  close  to  the  sides. 
Bring  the  ends  out  on  either  side,  between  the  chest-wall 
and  the  arms.  • 


552 


THE   OPERATIXG-ROOM 


Turn  the  ends  over  and  under  the  extended  arms,  and 
tuck  them  back  well  under  the  patient. 

In  tucking,  leave  a  few  inches  of  the  margin  hanging 
out;  with  one  quick  pull  on  the  free  margin  the  arm  is 
instantly  freed. 

Patients  may  also  require  to  be  placed  in  the  lithotomy 
position,  with  the  knees  flexed,  as  described,  with  the 
crutches,  in  the  Trendelenburg  or  Sims'  positions  (Chap. 
VI),  on  the  side,  or  with  one  or  other  limb  extended  on  a 
separate  attachment  of  the  table.  A  nurse  often  finds  the 
arrangement  of  a  patient  in  his  unconscious  condition  one 
of  her  most  difficult  duties;  she  should  be  given  the  oppor- 


Fig.  170. — Showing  method  of  fixing  arms  during  operation. 

tunity  to  practise  until  she  can  do  it  deftly,  and  carry  out 
any  change  of  position  during  the  operation  without 
unduly  disturbing  the  operation  or  coming  in  contact  with 
sterile  objects. 

The  patient  in  place,  she  next  arranges  the  rubber  sheet- 
ing, one  above  and  one  below  the  site  of  operation,  re- 
moves the  bandage  and  top  preparation  dressing,  and  waits 
on  the  clean  assistant  as  she  prepares  the  area. 

During  the  operation  she  must  be  on  the  alert  to  fore- 
stall the  wants  of  the  operator  or  his  assistants  or  of  the 
clean  nurse;  she  changes  the  lotions,  keeps  up  the  supply 
of  towels  and  sponges,  sterilizes  instruments  that  may  be 


DUTIES  OF  THE   NURSES  553 

called  for,  and  performs  any  service  about  the  table  for 
which  an  unsterilized  pair  of  hands  may  be  required. 
She  is  expected  to  keep  close  watch  that  technic  is  not 
broken,  and  to  call  the  attention  of  one  of  the  assistant 
operators  to  the  fact  in  the  event  of  its  occurring. 

In  emergencies  she  may  be  required  to  administer  a 
hypodermic,  to  prepare  for  hypodermoclysis,  or  to  give 
a  stimulating  enema.  If  hypodermoclysis  is  required,  she 
prepares  the  necessary  apparatus,  hands  the  needle  and 
sterile  length  of  tubing  to  the  clean  nurse,  and  prepares  the 
skin  for  the  puncture.  When  all  is  ready,  the  clean  nurse 
removes  her  gloves  and  introduces  the  needle  into  the 
tissues,  with  the  usual  precautions;  the  rest  of  the  process 
is  usually  left  to  the  unsterile  nurse,  unless  an  extra  clean 
assistant  is  available  for  the  whole  process. 

If  irrigation  is  necessary,  the  nozzle  and  a  sterile  length 
of  tubing  are  brought  to  a  clean  assistant,  the  unsterile 
nurse  preparing  the  rest  of  the  apparatus.  In  connecting 
a  sterile  length  to  the  rest  of  the  tubing,  which  does  not 
remain  strictly  sterile,  she  holds  the  end  of  the  sterile 
tubing  with  a  piece  of  sterile  gauze.  The  unsterile  length 
of  tubing,  either  for  hypodermoclysis  or  for  irrigation, 
must  always  be  sufficiently  long  to  come  well  beyond  the 
sterile  coverings  of  the  operating  table.  At  the  present 
day  cavities  are  usually  irrigated,  when  necessary,  with 
normal  salt  solution  in  preference  to  sterile  water  or  an 
antiseptic  solution. 

Where  the  Paquelin  cautery  (p.  147)  is  to  be  used,  the 
unsterile  nurse  prepares  the  instrument,  heats  the  tip, 
and  manages  the  pump,  passing  the  handle  only  to  the 
operator,  who  takes  it  in  a  piece  of  sterile  gauze. 

Counting  Sponges,  etc. — One  of  the  most  important 
duties  of  the  nurses  during  an  operation  where  a  cavity  is 
opened  is  to  keep  count  of  the  sponges  and  of  the  instru- 
ments used,  especially  of  the  artery  forceps  (clips,  hemo- 
stats),  of  which  a  considerable  number  may  be  in  use. 
Accidents  have  occurred  in  which  a  sponge  or  a  pair  of 
forceps  has  been  left  in  the  abdomen. 

To  facilitate  the  counting  the  numbers  used  must  be 
known  accurately.  Sponges  are  given  to  the  clean  nurse 


554  THE   OPERATING-ROOM 

in  packets  of  a  known  number,  ten  or  twenty  usually,  and 
the  forceps  in  bunches  of  six  strung  together  on  a  safety-pin. 
On  receiving  the  sponges  the  clean  nurse  counts  them  twice, 
and  writes  the  number  on  a  piece  of  sterile  slate  placed  on 
her  table.  As  the  sponges  are  used  and  discarded  the 
unsterile  nurse  places  them  on  one  side  and  recounts 
them,  entering  the  number  in  tens  or  twenties  in  writing. 
Before  the  cavity  is  closed,  the  two  counts  are  taken  and 
compared,  to  insure  that  no  sponge  is  left  in  the  cavity. 
The  same  care  is  taken  with  the  instruments.  If  an  in- 
strument falls  fron  the  table  or  becomes  otherwise  unsterile, 
it  is  either  resterilized  and  returned  to  the  clean  nurse 
for  use  again,  or  put  on  one  side,  to  be  counted  with  the 
instruments.  It  is  usually  a  rule,  in  such  cases,  that  no 
sponge  or  instrument  put  out  for  an  operation  may  be 
taken  from  the  operating-room  during  the  operation. 
The  nurse  must  never  hesitate  to  notify  the  operator  before 
he  begins  closing  the  wound  if  she  finds  herself  with  a 
sponge  or  instrument  short.  The  operation  is  then  stopped 
until  the  missing  article  is  found. 

Some  surgeons  have  the  sponges  for  abdominal  sections 
made  after  special  patterns,  to  lessen  the  risk  of  such  an 
accident.  Some  use  wide  strips  of  gauze,  about  two  yards 
long,  folded  so  as  to  avoid  raw  edges,  and  rolled  like  a 
bandage;  others  have  special  pads  of  gauze  made  to  which 
a  length  of  tape  is  sewn ;  a  pair  of  artery  forceps  clipped  to 
this  tape  acts  as  an  additional  guard.  Once  a  piece  of 
gauze  is  saturated  with  blood,  it  may  easily  be  lost  sight 
of  among  the  tissues  and  get  buried  under  a  coil  of  intes- 
tines or  other  viscera. 

When  the  incision  is  closed,  instruments  and  soiled 
towels  are  removed  and  the  skin  cleaned  and  driecl  before 
the  dressings  are  applied.  The  dressings  should  not  be 
taken  from  their  coverings  until  immediately  required; 
there  is  no  object  in  leaving  them  uncovered  on  a  table 
during  an  operation  that  may  last  an  hour  or  more. 

The  dressing  applied,  the  unsterile  nurse  may  be  required 
to  help  in  the  adjustment  of  the  bandage  and  in  drying 
the  patient  and  removing  him  on  to  the  stretcher.  Par- 
ticular care  should  be  exercised  in  drying  the  back  thor- 


OPERATIONS   IN   THE    PATIENT'S   HOME  555 

oughly.  The  covering  blanket  must  be  changed  if  wet, 
as  it  is  important  to  return  the  patient  to  bed  in  warm, 
dry  clothes. 

One  nurse  should  always  accompany  the  patient  with 
the  anesthetist  to  the  ward,  where  she  should  give  the  head 
nurse  a  written  memorandum  of  any  emergency  treatment 
that  has  been  necessary  during  the  operation;  thus: 

11  A.  M.  :  Hypodermic  strychnin  sulphate,  -£$  grain. 

11.15  A.  M.:  Hypodermoclysis  normal  salt  solution, 
500  c.c. 

These  are  entered  on  the  special  chart  (p.  217); 
nothing  of  this  sort  should  be  left  to  the  spoken  word — 
memories  are  too  uncertain.  She  should  also  mention 
briefly  anything  that  has  been  done  other  than  the  opera- 
tion for  which  the  patient  was  prepared. 

Between  operations  the  unsterile  nurse  removes  soiled 
things  from  the  operating-room,  places  stained  instru- 
ments to  soak  in  cold  water,  wipes  the  table,  if  the  same  is 
to  be  used  again,  with  a  towel  wrung  out  in  the  antiseptic 
preferred,  mops  the  floor,  changes  the  lotions,  water,  etc., 
and  replenishes  the  different  tables  with  all  that  is  required, 
bringing,  as  before,  the  sterile  towels,  sponges,  etc.,  to  the 
clean  nurse  in  their  packets,  and  the  freshly  sterilized 
instruments  in  their  tray. 

In  all  large  schools  many  of  the  duties  assigned  to  the 
unsterile  nurse  are  performed  by  orderlies.  The  more, 
however,  a  nurse  does  herself  of  the  actual  work,  just  so 
much  the  more  thorough  is  her  training. 

OPERATIONS  IN  THE  PATIENT'S  HOME 
A  very  large  proportion  of  a  private  nurse's  work  at  the 
present  day  is  surgical.  Frequently  she  is  called  upon  at 
short  notice  to  prepare  for  an  operation.  The  prepara- 
tion will  include  not  only  the  patient,  with  the  details  of 
which  process  she  is  familiar,  but  the  preparation  of  the 
room  and  the  operating-room  equipment.  For  the  for- 
mer she  will  receive  definite  instructions  from  the  surgeon; 
for  the  latter  she  may  find  herself  left  altogether  to  her  own 
ingenuity,  and  must  be  prepared  to  arrange  a  modern 
operating-room  from  furniture,  utensils,  etc.,  intended  for 


556  THE   OPERATING-ROOM 

entirely  alien  purposes.  As  a  rule,  nurses  enjoy  this  part 
of  the  work,  and  it  is  more  necessary  to  warn  them  against 
unnecessary  extravagance  in  their  demands  than  to  sug- 
gest ways  in  which  what  they  find  to  hand  can  be  trans- 
formed into  the  requirements  of  the  occasion. 

Requirements. — In  order  that  nothing  may  be  over- 
looked, the  best  surgical  nurses  invariably  keep  a  list  of 
what  is  necessary  to  prepare,  so  easy  is  it,  in  trusting  to 
the  requirements  of  the  moment,  to  overlook  something 
essential. 

The  instruments  the  surgeon  brings  with  him,  and  the 
anesthetist,  as  a  rule,  provides  the  anesthetic  and  the  cone 
or  mask. 

In  a  city  a  nurse  will  be  able  to  hire,  if  desired,  sterilized 
dressings,  towels,  gowns,  and  utensils  from  one  or  other 
of  the  nurses'  registries,  giving  notice  of  what  she  requires 
in  good  time.  In  many  circumstances  this  is,  however, 
out  of  the  question,  and  she  must  prepare  and  sterilize 
everything  herself  on  the  spot. 

The  dressings  and  the  solutions  required  are  generally 
ordered  especially  for  the  occasion  from  a  drug-store  or 
surgical  supply  place.  If  the  ordering  is  left  to  the  nurse, 
she  should  be  careful  not  to  order  more  than  will  be  used. 
One  dozen  tabloids  of  bichlorid  of  mercury  will  make  six 
quarts  of  solution  1  :  1000;  if  the  Kelly  preparation  is  to 
be  used,  one  ounce  of  permanganate  of  potash  crystals 
and  four  ounces  of  oxalic  acid  crystals  will  be  sufficient. 
A  pint  of  alcohol  (90  per  cent.)  may  be  ordered,  as  what  is 
not  used  in  the  preparation  of  the  skin  and  the  sterilizing 
of  knives  and  needles  may  be  used  later,  diluted  one-half 
with  water,  for  the  alcohol  rubs. 

Gauze  and  cotton  in  sterile  packets  from  the  drug-store 
are  expensive  items;  where  expense  is  a  consideration, 
they  may  be  bought  by  the  pound  and  by  the  yard  un- 
sterilized,  cut  into  the  necessary  dressings  and  sponges, 
and  wrapped  in  improvised  covers  for  sterilization.  The 
nurse  should  ask  especially  for  the  oldest  linen,  old  sheets, 
table-cloths,  towels,  and  dusters,  etc.,  or  old  discarded 
cotton  clothing  that  may  be  cut  up  into  wrappers  and 
towels.  Besides  the  dressings,  the  nurse  must  sterilize 


OPERATIONS   IN  THE  PATIENT'S  HOME  557 

a  good  supply  of  towels,  a  couple  of  sheets  to  cover  the 
patient  and  table  during  the  operation,  and  covers  for  the 
sterile  tables. 

Outfit. — Many  nurses  in  their  outfit  provide  themselves 
with  the  following  articles,  the  cost  of  which  is  trifling 
when  weighed  with  the  convenience  of  having  them  always 
at  hand: 

Gown  and  cap. 

Gloves,  rubber  and  white  cotton. 

Nail-brush,  file,  and  orange-wood  sticks. 

Hypodermic  syringe  and  two  needles. 

Scissors,  probe,  and  dressing  forceps. 

Rectal  tube  and  funnel. 

2  glass  catheters. 

Hypodcrmoclysis  needle,  with  rubber  tubing  and  glass 
siphon  tube. 

6-ounce  bottle  of  concentrated  sterile  salt  solution  (the 
cork  of  ground  glass) . 

Tabloids  of  bichlorid  of  mercury. 

Bottle  of  alcohol. 

Sterile  packets  of  gauze  and  cotton  (small  quantities). 

One  or  two  bandages  and  safety-pins. 

To  this  list  a  small  portable  instrument  sterilizer  and 
alcohol  lamp  are  often  added.  What  may  be  used  for  one 
patient  can  be  paid  for  at  cost  price  and  replaced. 

Infusion  of  normal  salt  solution  is  such  a  common  form 
of  treatment  in  all  conditions  of  lowered  vitality  that  the 
means  for  hypodermoclysis  should  be  at  hand,  at  all 
events  in  major  operations.  As  described  above,  this 
solution  can  be  procured  in  special  sealed  sterilized  flasks 
put  up  with  tubing  and  needle  complete.  The  nurse  has 
merely  to  bring  the  sojution  to  the  required  temperature 
by  placing  the  flask  on  a  gas-ring  or  in  a  hot-water  bath. 
Where  she  has  to  prepare  the  solution  herself,  she  will 
probably  be  unable  to  sterilize  either  by  the  fractional 
method  or  by  steam  under  pressure.  (See  Salt  Solution, 
p.  460.)  The  bottle  she  is  to  use  should  be  washed  clean 
of  dust  or  foreign  particles  and  sterilized  by  boiling  for 
half  an  hour.  The  water  should  boil  actively  for  twenty 
minutes  in  a  kettle  used  only  for  water  before  the  salt 


558  THE   OPERATING-ROOM 

solution  (or  salt)  is  added;  the  solution  is  then  filtered 
through  several  folds  of  sterile  gauze  until  absolutely 
clear,  poured  into  the  sterile  bottle,  and  placed  in  a  water- 
bath  to  boil  again  for  half  an  hour.  The  solution  can  be 
siphoned  directly  from  the  bottle,  using  a  sterile  glass 
drinking-tube  as  a  siphon,  to  which  the  rubber  tubing  and 
hypodermic  needle  are  attached. 

Sterilizer. — The  ordinary  clothes-boiler  makes  a  prac- 
tical sterilizer  for  dressings,  towels,  etc.,  as  already 
described  (p.  450).  These  should  be  sterilized,  when 
practical,  the  day  before  the  operation,  the  packets  dried 
off  in  the  oven  or  on  the  hot-water  pipes,  and  wrapped  until 
required  in  a  clean  sheet.  The  basins  and  other  utensils 
to  be  used  may  be  boiled  in  the  clothes-boiler  for  half 
an  hour  and  kept  in  the  boiler,  closely  covered  until  re- 
quired. If  this  is  impractical,  they  should  be  thoroughly 
scrubbed  and  immersed  in  an  antiseptic  (formalin,  2  per 
cent.;  carbolic,  1  :20;  or  bichlorid  of  mercury,  1  :  500) 
at  least  a  full  hour  before  the  operation.  The  bath-tub 
or  a  good-sized  laundry  tub  can  generally  be  used  for 
this  purpose.  The  nurse  should  sterilize  a  couple  of  basins 
for  hand  lotion,  a  couple  of  pitchers  for  sterile  water,  etc., 
and  two  or  three  smaller  basins  or  bowls  for  various  uses. 
A  flat  pie-dish  is  a  useful  substitute  for  a  kidney-shaped 
pus-bowl,  and  a  soap-dish,  a  convenient  size  to  provide 
for  the  anesthetist's  table.  A  graduate  measure  or  a 
small  pitcher  of  known  capacity  for  measuring  solutions 
should  be  included.  A  couple  of  buckets,  slop-jars,  or  a 
good-sized  tub  should  be  scrubbed  clean  to  collect  used 
sponges,  etc. 

Sterile  water  will  be  required,  both  hot  and  cold. 
Boiled  water,  kept  in  the  receptacle  in  which  it  has  been 
boiled,  is  generally  accepted  as  sterile.  Time  must  be 
allowed  for  one  kettleful  to  be  quite  cold  by  the  hour  of  the 
operation.  To  cool  a  kettleful  quickly,  stand  the  kettle 
in  the  sink,  the  lid  in  place,  and  let  the  cold  water  run 
over  it. 

Room. — The  nurse  frequently  has  the  responsibility 
of  deciding  upon  the  room  to  be  used  for  the  operation 
and  selecting  the  furniture.  Remember  that  what  the 


OPERATIONS   IN   THE   PATIENT'S   HOME  559 

surgeon  wants  chiefly  is  a  good  light,  a  steady  table,  and 
no  dust;  what  the  family  hope  is  that  you  will  neither 
waste  nor  spoil  their  things. 

A  room  that  is  too  sunny  is  almost  as  great  a  disad- 
vantage as  a  room  that  is  too  dark;  for  this  reason  a  south 
room  is,  speaking  generally,  to  be  avoided;  a  north  room 
with  a  good  window  is  the  ideal  choice,  a  north  light  being 
always  clearer  than  any  other;  for  a  morning  operation 
a  west  light  is  practical,  or  an  east  room  if  the  operation  is 
in  the  afternoon.  If  the  window  is  overlooked,  the  glass 
may  be  made  opaque  by  rubbing  over  with  soap,  or  a  piece 
of  mosquito-netting  may  be  tacked  tightly  across.  This 
should  always  be  done  if,  as  in  the  heat  of  summer,  the 
window  is  to  be  open  and  is  not  already  screened,  and  is 
especially  necessary  in  cities,  where  the  air  is  grimy  and 
dust-laden. 

That  the  room  should  be  absolutely  clean,  a  nurse  will 
recognize  as  a  first  essential.  If  she  arrives  at  least  a  full 
day  before  the  operation,  she  has  time  to  make  it  so.  All 
hangings,  curtains,  carpets,  pictures,  and  movable  decora- 
tions should  be  removed,  the  walls  and  ceiling  swept  down, 
the  floor  and  woodwork  washed.  If,  however,  she  arrives 
only  the  morning  of  the  operation,  a  strenuous  cleaning 
will  only  set  dust  floating  in  the  air.  Usually  some  one  will 
be  available  to  wash  the  floor,  and  the  nurse  must  be  con- 
tent with  removing  the  hangings,  carpet,  lighter  furniture, 
and  wiping  everything  within  reach  with  a  cloth  wrung  out 
with  a  disinfectant. 

Where  it  has  been  possible  to  prepare  the  room  the 
day  before  it  is  an  excellent  plan,  especially  if  the  walls 
are  papered,  to  disinfect  by  some  simple  means.  A  sheet 
wrung  out  of  formalin,  10  per  cent.,  may  be  hung  over  a 
screen,  and  a  basinful  of  the  same  solution  be  sprinkled 
with  a  clean  whisk  over  the  room.  Doors  and  windows  are 
closed  for  six  hours,  after  which  air  is  admitted  freely 
through  the  screened  window.  If  the  case  is  not  "  clean," 
the  process  may  be  repeated  after  the  operation  before 
the  room  is  again  used  by  the  family. 

Other  considerations  will  also  influence  the  choice  of  the 
operating-room.  The  room  should,  unless  in  a  house 


560  THE   OPERATING-ROOM 

with  an  elevator,  be  on  the  same  floor  as  the  patient's 
bed-room;  it  should  be  as  quiet  as  attainable,  and  espe- 
cially removed  from  the  noise  of  streets  or  the  shaking  of 
passing  trains  or  cars. 

To  equip  the  room  for  an  operating-room,  the  nurse 
will  get  ready  an  operating-table,  a  "  sterile  "  table,  a 
reserve  table  for  pitchers,  water,  lotion,  and  unsterile 
objects,  a  couple  of  small  tables,  stools,  or  chairs,  one 
for  hand  lotion,  and  one  for  the  anesthetist,  also  a  chair 
for  the  latter;  a  wash-stand  for  the  surgeon  to  prepare  his 
hands  is  added,  unless  a  bath-room  is  available. 

Table. — The  solid,  narrow,  old-fashioned  kitchen  table 
makes  the  best  operating-table,  or  a  well-made  dining 
table.  If  no  table  long  enough  is  available,  two  of  the 
same  height  can  be  tied  together  firmly  by  the  legs. 

To  protect  the  table  from  staining,  it  should  be  covered 
first  with  a  rubber  sheet.  The  oil-cloth  often  used  in  coun- 
try kitchens  as  a  table-cloth  makes  a  practical  substitute 
for  a  rubber  sheet  if  one  is  not  procurable;  failing  this,  sev- 
eral thicknesses  of  newspaper  will  answer  the  purpose.  The 
pad  is  made  of  a  blanket  folded  to  the  exact  size  of  the 
table;  this  is  covered  with  a  second  rubber  sheet,  and  the 
whole  folded  tidily  in  a  sheet.  To  prevent  slipping,  the  pad 
should  be  secured  to  the  table  with  strips  of  a  wide  band- 
age passed  over  the  pad  and  tied  below  the  table.  A  clean 
old  blanket  will  be  necessary  to  cover  the  patient,  and  a 
couple  of  small  sheets  should  be  sterilized  to  use  during  the 
operation. 

Position  of  Patient. — If  it  is  necessary  to  place  the  pa- 
tient in  the  Trendelenburg  position,  a  chair  may  be  placed 
on  the  table,  as  described  previously  (p.  234),  and  the 
whole  covered  with  the  operating  pad.  In  order  to  raise 
the  table,  either  the  whole  or  one  end,  blocks  may  be  made 
of  bundles  of  magazines  tied  firmly  in  packets  and  covered 
in  newspapers  or  old  towels,  or  hassocks  may  be  wrapped 
in  newspaper  or  covered  with  old  towels. 

If  the  lithotomy  position  is  required,  the  patient  is 
brought  to  the  bottom  of  the  table,  the  legs  elevated  and 
separated,  the  knees  flexed,  and  the  feet  made  to  rest  on 
a  couple  of  small  tables  or  high  stools,  placed  beside  the 


OPERATIONS   IX   THE    PATIENT'S   HOME  561 

bottom  of  the  table.  The  feet  are  tied  in  position  with  a 
wide  bandage.  The  position  may  also  be  kept  by  tying 
each  ankle  to  the  wrist  on  the  same  side.  This  is,  how- 
ever, an  awkward  method  if  it  should  be  necessary,  as  in 
an  emergency,  to  alter  the  position  of  the  patient  suddenly. 
All  the  tables  should  be  protected  by  newspapers  of  several 
thicknesses,  covered  with  a  clean  towel.  If  the  furniture 
is  polished,  ask  for  some  plain  wooden  boards  to  cover  those 
on  which  lotion,  water,  etc.,  are  to  be  placed;  an  ironing- 
board  makes  an  excellent  stand  for  pitchers  of  hot  water 
and  lotion  bowls. 

To  protect  the  floor,  unless  a  large  rubber  sheet  is  avail- 
able, it  may  be  covered  with  several  thicknesses  of  news- 
papers, over  which  a  clean  old  sheet  or  curtain  is  stretched 
and  tacked  down.  Unless  the  floor  is  of  brick  or  stone, 
special  attention  should  be  paid  to  this  part  of  the  prepa- 
ration. Blood-stains  are  very  unsightly,  and  are  difficult 
to  remove  entirely  from  wood,  especially  unvarnished 
wood.  In  country  homes  a  piece  of  tarpaulin  can  gener- 
ally be  procured  for  the  purpose;  it  must,  of  course,  be 
absolutely  clean. 

Sterilizing  Instruments. — The  instruments  can  be 
boiled  in  any  vessel  of  convenient  size,  provided  with  a  lid; 
they  should  be  placed  first  on  a  flat  pie-dish  or  cake-tin, 
in  which  they  can  be  removed  without  handling  the  in- 
struments. A  small  fish-kettle,  with  its  movable  perforated 
tray,  makes  a  perfect  instrument  sterilizer,  and  can  be 
boiled  on  the  kitchen  stove.  A  small  flat  dish  should  be 
sterilized  and  filled  with  alcohol  for  the  knives  and  needles, 
as  it  is  frequently  preferred  not  to  boil  them  (p.  479). 

Arrangement  of  Room. — The  sterile  table,  covered  with 
a  sterile  towel,  is  placed  beside  the  surgeon's  assistant, 
and  on  it  are  arranged  the  instruments,  needles,  ligatures, 
sutures,  and  sponges;  the  latter  counted  and  the  count 
written  down. 

On  the  unsterile  table  are  the  packets  of  dressings, 
towels,  gowns,  etc.,  the  pitchers  of  water  and  lotion,  the 
latter  covered  with  a  towel  wrung  out  of  the  antiseptic 
solution,  the  requisite  for  the  skin  preparation,  the  salt 
solution,  bandages,  pins,  etc. — all  that  is  to  be  handled  by 

36 


562  THE   OPERATING-ROOM 

the  unsterile  assistant.  A  watch  or  clock,  and  a  pencil  and 
paper  should  not  be  forgotten;  any  special  treatment 
should  be  noted  in  writing. 

The  stool  or  chair  for  the  hand  lotion  is  also  covered 
with  a  sterile  towel  and  placed  close  to  the  operating  sur- 
geon ;  if  a  chair  is  used,  the  back  is  also  covered ;  the  gloves 
can  be  placed  in  this  lotion. 

The  anesthetist's  chair  and  small  table  are  placed  at  the 
head  of  the  table.  On  this  table  are  placed  a  soap-dish, 
a  sterile  glass  containing  sterile  water,  a  second  with  a 
little  alcohol,  some  squares  of  old  clean  linen  or  cut  gauze, 
the  hypodermic  tabloids,  and  a  hypodermic  syringe,  ster- 
ilized and  wrapped  in  a  gauze  sponge  soaked  in  alcohol. 
The  anesthetic  and  apparatus  are  usually  brought  by  the 
anesthetist,  who  will  also  probably  have  with  him  the 
usual  hypodermic  tabloids. 

If  irrigation  is  to  be  expected,  a  Kelly  pad  or  its 
equivalent  must  be  prepared.  A  rubber  sheet,  or,  fail- 
ing this,  wax  cloth  may  be  used.  At  one  end  is  placed 
a  lightly  rolled  small  blanket  (or  newspaper,  etc.),  and 
the  rubber  is  rolled  over  the  blanket  for  about  a  third 
of  its  length,  forming  a  little  bolster.  The  bolster  is  bent 
round  like  a  horseshoe,  and  forms  the  pad,  the  free  part  of 
the  sheet  forming  the  apron. 

On  the  floor  may  stand  conveniently  the  kettles  of  hot 
and  cold  sterile  water,  the  tub  or  wash-boiler  with  the 
sterilized  basins  and  bowls,  and  a  slop-jar  for  the  used 
sponges. 

Gowns. — A  nurse  who  is  doing  surgical  work  will  have 
an  operating  gown  and  cap  in  her  outfit.  In  an  emergency 
she  can  sterilize  a  large  gingham  apron  and  simple  cotton 
blouse  with  the  dressings,  and  cover  her  head  with  a 
sterile  towel.  A  sheet  also  can  be  converted  into  a  fairly 
practical  sterile  gown,  either  for  herself  or  the  surgeons. 
Before  sterilizing,  the  sheet  is  folded  so  that  the  two  ends 
come  together  at  the  back,  allowing  sufficient  space  for 
the  neck;  the  upper  margins  are  then  pinned  together 
closely  with  safety-pins  (or  stitched  together)  over  either 
shoulder  and  the  upper  part  of  the  arm,  leaving  enough 
room  for  the  arms  to  be  thrust  through,  much  after  the 


OPERATIONS   IN   THE   PATIENT'S   HOME  563 

manner  of  the  Greek  dress.  The  impromptu  gown  is 
pinned  behind  at  the  neck,  and  if  too  voluminous,  may  be 
tied  round  the  waist  with  a  sterile  bandage. 

For  carrying  a  patient  to  and  fro,  a  light  rattan  porch 
couch  may  be  available,  or  a  stretcher  may  be  improvised 
in  several  ways.  The  patient  is  carried  feet  first. 

A  couple  of  plain,  high-backed  chairs  may  be  tied 
together  firmly,  the  back  of  one  overlapping  the  back  of 
the  other;  on  this  two  or  three  cushions  are  laid,  on  which 
the  patient  lies  flat,  the  legs  of  the  chair  forming  the  handles 
of  the  stretcher.  This  stretcher  is  too  short  for  the 
patient's  legs,  which  are  thrust  through  the  arms  of  the  fore- 
most carrier;  in  many  homes  it  is  impossible,  however,  to  get 
a  longer  stretcher  through  the  narrow  doors  and  landings. 

A  stretcher  may  also  be  made  out  of  a  couple  of  stout 
sacks,  such  as  are  used  for  flour  or  potatoes,  and  a  pair  of 
light  curtain-poles;  at  either  end  a  walking-stick  is  firmly 
tied  to  each  pole,  to  keep  them  sufficiently  apart.  Where 
no  stretcher  can  be  contrived,  the  patient  may  be  carried 
in  his  sheet,  one  carrier  at  the  head,  one  at  either  side,  and 
one  at  the  feet. 

Frequently  the  patient  is  nursed  afterward  in  the  room 
prepared  for  the  operation,  and  is  then  easily  lifted  from 
the  table  to  the  bed.  If  his  former  bedroom  is  on  the 
same  floor,  he  may  in  many  cases  be  allowed  to  walk  to 
the  operating-room,  or  be  carried  in  the  upright  position. 
A  carrying  chair  is  easily  made  from  a  piece  of  strong 
ticking  cut  the  shape  and  size  of  the  seat  of  an  ordinary 
chair;  the  sides  are  strongly  stitched  with  wide  hems, 
through  which  short  stout  poles  are  thrust.  This  is  a 
comfortable  way  of  carrying  a  patient,  and  can  be  taken 
up  and  down  a  narrow  staircase  much  more  easily  than 
any  ordinary  carrying  chair. 

A  nurse  who  knows  exactly  what  she  requires  will  be 
able  to  set  available  members  of  the  family  to  help  in 
preparing  the  room,  etc.,  while  she  is  busy  with  the  patient, 
who  may  often  leave  her  time  for  little  else.  She  will 
generally  find  they  are  thankful  to  have  something  definite 
to  do  to  keep  their  thoughts  from  the  ordeal  before  them. 

In   the   houses  of  the   very  wealthy,  the  nurse  will 


564  THE    Ol'EKATING-ROOM 

have  little  trouble.  The  surgeon  in  a  wealthy  practice 
usually  has  his  own  operating  nurse,  trained  exactly 
in  his  ways,  who  brings  with  her  all  that  is  required, 
even  to  a  portable  operating-table.  It  is  in  the  homes 
where  expense  is  a  consideration  that  she  will  most 
often  have  to  exercise  her  ingenuity.  She  should  make  it 
her  pride,  as  well  as  one  of  her  special  duties,  to  reduce 
her  requirements  to  a  minimum.  We  often  see  at  the 
present  day  "  demonstrations  "  given  to  pupil  nurses  on 
the  subject  of  preparing  an  ordinary  room  for  an  operation. 
The  ingenuity  shown  and  the  dainty  effect  produced  are 
certainly  to  be  commended,  as  well  as  the  excellent 
technic  practised.  One  remembers  a  demonstration 
where  it  was  recommended  to  hang  clean  sheets  round 
the  walls  from  the  picture-line;  where  the  backs  of  chairs 
were  encased  in  pillow-covers,  and  numerous  sheets  and 
table  cloths  used  skilfully  to  cover  all  the  necessary  fur- 
niture. The  effect  was  produced  at  the  cost  of  a  very  large 
laundry-bill,  and  nothing  but  effect  was  really  gained. 
No  sensible  woman  would  do  anything  but  censure  such 
needless  extravagance,  and  one  would  beg  nurses  to  realize 
that  it  is  by  such  thoughtlessness  that  they  are  among 
»o  many  a  byword  for  extravagance,  and  their  presence  so 
often  looked  upon  as  an  intolerable  burden. 

After  the  operation  the  nurse  will  necessarily  be  occupied 
entirely  with  her  patient  for  some  hours,  and  unless  the 
operation  is  performed  in  the  patient's  own  room,  she  must 
leave  clearing  up  until  later.  She  should  see,  however, 
that  all  stained  linen  is  placed  at  once  to  soak  in  cold  water, 
and  that  the  room  is  left  in  as  little  an  unsightly  condition 
as  possible.  A  good  training  should  teach  a  nurse  to  do 
all  work  in  an  orderly  way,  and  to  "  clear  as  she  goes." 

The  instruments  she  can  take  with  her,  usually  to  the 
patient's  room,  removing  the  stains  with  cold  water  and 
drying  with  a  little  alcohol.  The  surgeon  will  generally 
get  them  cleaned  and  sterilized  in  his  own  office. 

If  a  nurse  intends  to  take  up  surgical  nursing  specially, 
she  will  be  wise  to  spend  some  weeks  in  helping  an  ex- 
perienced nurse  in  the  preparation  for  operation  cases,  so 
difficult  is  it  to  realize  conditions  or  imagine  emergencies 
from  any  but  the  standpoint  of  experience. 


CHAPTER  XVI 
THE  CARE  OF  OPERATION  CASES 

Preparatory  Period — Immediate  Preparation — Ether  Bed — After- 
care— Restlessness,  Nausea  and  Vomiting,  Thirst — Abdominal  Sec- 
tion— Distention — Stercoraceous  Vomiting — Shock — Hemorrhage — 
Sepsis — Care  of  Eye  Operations — Tracheotomy — Intubation. 

PREPARATION  OF  THE  PATIENT 

THE  care  of  operation  cases,  especially  major  operations, 
should  begin,  whenever  possible,  two  days  before  the  day 
of  operation. 

The  Preparatory  Period. — During  the  preparatory 
period  all  physical  fatigue  and  mental  excitement  or  worry 
should  be  avoided;  to  insure  this,  many  surgeons,  and 
especially  gynecologists,  keep  the  patient  in  bed  and  forbid 
all  visitors  for  from  twenty-four  to  forty-eight  hours  before 
the  day  of  operation. 

In  hospital  patients  the  heart  and  lungs  are  examined  on 
admission  as  a  routine  duty,  and  a  specimen  of  urine  is 
saved  for  examination.  These  examinations  are  repeated 
on  the  morning  of  the  operation;  the  patient  should  not 
be  sent  to  the  operating-room  until  the  report  of  the 
urinary  analysis  has  been  returned  (p.  285). 

Catharsis. — If  the  patient  has  a  history  of  constipation 
or  other  intestinal  irregularity,  some  form  of  catharsis  is 
begun  at  once.  Many  surgeons  order  a  course  of  calomel 
as  a  routine  treatment.  In  normal  conditions,  however, 
treatment  is  frequently  not  begun  until  the  day  before  the 
operation. 

According  to  the  hour  of  the  operation,  a  purgative 
is  administered,  either  in  the  morning  or  the  afternoon 
of  the  day  before  the  operation.  If  the  purgative  does 
not  act  in  six  hours,  the  dose  is  either  repeated  or  an  enema 
is  given  to  excite  the  peristalsis. 

565 


506  THE   CARE   OF   OPERATION   CASES 

On  the  day  of  the  operation,  usually  six  hours  before 
the  time  fixed  for  the  operation,  a  copious  enema  of  warm 
suds  is  given.  This  is  repeated  in  two  hours,  and  again  if 
necessary,  until  the  fluid  returns  clear,  which  is  a  sign  that 
the  lower  bowel  is  empty.  The  purgatives  preferred  are 
salts  of  magnesia  or  castor  oil,  but  some  surgeons  pre- 
scribe milder  drugs. 

For  operations  on  the  rectum  thorough  catharsis  is 
especially  essential.  Treatment  is  begun  at  least  forty- 
eight  hours  before  the  operation.  For  the  twenty-four 
hours  prior  to  the  operation  only  liquid  diet  is  given,  and 
special  care  is  taken  in  giving  the  enema  to  insure  that  the 
bowel  is  thoroughly  emptied. 

In  operations  for  chronic  conditions  on  any  part  of  the 
alimentary  tract,  as,  for  example,  in  the  radical  cure  for 
hernia,  the  same  care  is  necessary. 

In  emergency  operations  thorough  preparation  is  not 
possible.  If  more  than  four  hours  elapse  between  the  ad- 
mission of  the  patient  and  the  operation,  a  suds  enema 
may  be  ordered,  otherwise  the  bowels  are  left  undisturbed. 
An  exception  may  be  made  in  the  case  of  injuries  pro- 
ducing compression  of  the  brain;  in  this  case  a  drastic, 
quick-acting  purgative,  such  as  croton  oil  (1  to  2  minims), 
is  frequently  ordered.  All  nourishment  is,  of  course, 
withheld. 

In  acute  abdominal  conditions,  such  as  appendicitis, 
intussusception,  obstruction,  perforation,  etc.,  no  treat- 
ment of  any  sort  is  given  without  special  orders.  An 
enema  may  be  ordered,  but  commonly  even  this  is  omitted. 

The  diet  is  nourishing  and  digestible,  avoiding  fried 
foods,  coarse  vegetables,  and  highly  seasoned  or  rich 
dishes. 

The  patient  is  usually  given  his  ordinary  meals  until 
the  evening  before  the  day  of  operation.  On  this  evening 
a  light  supper  is  served,  as,  for  example,  a  cup  of  clear 
broth,  sweetbreads,  or  oysters,  without  vegetables,  and 
a  simple  dessert.  After  this  meal  no  solids  are  given, 
unless  the  operation  is  to  take  place  later  than  12  noon. 
In  this  case  a  breakfast  of  tea  or  coffee,  roll,  or  a  piece  of 
toast  and  a  soft-boiled  egg  may  be  ordered.  Four  hours 


PREPARATION    OF  THE    PATIENT  567 

before  the  operation  a  small  cup  of  hot  broth  or  beef-tea  is 
given,  and  nothing  further. 

The  reasons  for  such  preparation  are  readily  under- 
stood. If  food  is  present  in  the  stomach,  vomiting  will 
occur.  The  convulsive  retching  accompanying  the  act 
interferes  with  the  operation,  and  in  some  cases  may 
actually  be  dangerous.  At  the  same  time  there  is  risk 
of  the  vomited  matter  falling  into  the  larynx  and  choking 
the  patient.  If  the  rectum  is  not  emptied,  the  bowels 
will  probably  act  when  the  sphincters  become  relaxed 
under  the  anesthetic,  while,  if  the  intestines  are  distended 
with  food  or  gas,  they  are  more  liable  to  injury  if  the 
abdominal  cavity  is  opened. 

Cleansing. — During  the  preparatory  period  a  hot  tub- 
bath  is  given  to  the  patient  daily,  taking  special  care  to 
cleanse  the  area  of  the  operation  thoroughly.  (For  the 
local  preparation  see  Chap.  XIII.) 

For  an  abdominal  operation  the  nurse  should  herself 
examine  the  abdomen  and  make  sure  that  the  umbilicus 
is  perfectly  clean.  If  this  is  not  the  case,  it  should  be  well 
washed,  and,  if  necessary,  a  small  soap  poultice  applied. 
It  is,  however,  always  a  disadvantage  to  irritate  the 
tissues. 

Immediate  Preparation. — An  hour  before  the  operation 
the  immediate  treatment  of  the  patient  is  begun.  The 
temperature,  pulse,  and  respiration  are  taken  and  charted. 
A  woman  has  her  hair  brushed  and  braided  in  two  plaits, 
which  are  pinned  out  of  the  way  round  her  head.  Any 
false  teeth  are  removed.  The  clothing  usually  consists 
of  the  loose  jacket  and  long  hose  of  Canton  flannel  already 
described;  in  private  work  an  old  night-gown  should  be 
used,  choosing  one  that  is  loose  round  the  neck.  For 
operations  on  the  face,  mouth,  nose,  etc.,  the  hair  is  cov- 
ered with  a  rubber  bathing-cap. 

A  quarter  of  an  hour  before  the  time  set  for  the  anes- 
thetic the  urine  is  voided.  If  the  operation  is  on  the  pelvic 
organs,  the  patient  is  usually  catheterized,  and  a  note  to 
that  effect  made  on  the  chart,  with  the  hour  and  the 
quantity  of  urine  obtained  clearly  stated.  The  charts 
and  history  notes  generally  accompany  the  patient  to 


568  THE   CAKE   OF   OPERATION   CASES 

the  operating-room.  In  special  conditions  a  stimulating 
enema  is  ordered  to  be  given  half  an  hour  before  the  anes- 
thetic is  begun.  In  other  cases  a  hypodermic  injection, 
usually  of  atropin  and  morphin,  may  be  given  immediately 
before  the  anesthetic.  These,  as  a  rule,  are  special  orders, 
and  not  part  of  the  routine  treatment;  they  must  be  en- 
tered on  the  chart  before  it  is  sent  to  the  operating-room. 

ETHERIZATION 

For  all  major  operations  the  patient  is  taken  to  the  ether- 
izing room  on  a  stretcher;  in  some  minor  cases  a  wheel- 
chair is  permissible;  it  is  undesirable  that  a  patient  should 
walk  or  stand  immediately  before  taking  an  anesthetic. 

It  may  be  necessary  to  etherize  the  patient  in  his  own 
bed.  As  the  bottom  rail  is  usually  lower  than  the  head- 
rail  and  stands  free  from  the  wall,  the  patient  lies  with  the 
head  at  the  bottom  of  the  bed,  a  single  pillow  under  the 
head. 

Until  the  patient  loses  consciousness,  the  struggling 
movements  are  merely  guided  to  prevent  the  patient 
injuring  himself,  and  no  force  is  used.  During  the  few 
moments  when  consciousness  has  been  lost,  and  before 
relaxation  has  set  in,  considerable  strength  is  frequently 
necessary  to  control  the  patient  and  prevent  his  injuring 
himself. 

The  greatest  quiet  should  be  maintained  during  the 
giving  of  an  anesthetic.  The  patient's  hearing  is  pre- 
ternaturally  acute,  and  his  nervousness  is  much  increased 
by  chance  noises  or  talking.  At  the  same  time  he  is  liable 
to  misunderstand  words  that  are  used  and  take  all  remarks 
as  allusions  to  his  own  condition,  often  working  himself  into 
a  state  of  needless  alarm.  Irrelevant  topics  are  obviously 
out  of  place,  and  rightly  construed  as  heartless  and  un- 
dignified. 

The  ward  nurse  usually  remains  with  the  patient  until 
he  is  placed  on  the  operating  table  in  the  required  position. 
She  should  see  that  the  pads  or  pillows  are  adjusted  to 
prevent  his  back  being  injured  by  pressure  on  the  table. 
In  the  ordinary  position  the  lower  half  of  the  body  is 
wrapped  in  a  warmed  blanket,  over  which  a  rubber  sheet  is 


ETHERIZATION 


509 


tucked  until  after  the  cleaning-up  process  is  finished,  when 
it  is  replaced  by  the  sterile  sheets  and  towels. 

Records  of  the  pulse,  respiration,  physical  treatment 
during  an  operation,  and  some  details  of  the  operation  are 
kept  by  the  anesthetizer,  and  are  not  usually  the  respon- 
sibility of  the  nurse.  In  small  hospitals,  however,  where 
there  is  not  much  assistance,  the  care  of  the  pulse  is  some- 
times given  to  a  nurse.  In  this  case  she  should  realize  the 
importance  of  her  responsibility,  and  not  for  one  moment 
let  her  attention  wander  from  her  special  duty  to  the 
details  of  the  operation. 


Fig.  171. — Ether  bed  No.  1:  A  bed  arranged  for  return  of  a  patient 
from  operation. 

The  Ether  Bed. — As  soon  as  the  patient  has  been  sent 
to  the  operating-room,  the  bed  is  stripped,  the  room  aired 
and  put  in  order,  and  the  ether  bed  is  made  up. 

A  full-length  rubber  sheet  is  spread  over  the  mattress 
and  on  the  top  of  this  the  under  sheet;  on  the  top  of  the 
sheet  a  cross  rubber  sheet  and  draw-sheet.  A  clean  towel 
is  laid  in  place  of  the  pillows,  which  are  removed  unless, 
as  in  some  head  operations,  orders  are  given  to  the  con- 
trary. 

Three  or  four  cans  filled  with  boiling  hot  water  are 


570 


THE  CARE  OF  OPERATION  CASES 


placed  on  the  bed  and  covered  with  a  blanket.  These 
are  removed  before  the  patient  is  placed  back  in  bed. 
The  upper  coverings,  sheet,  blanket,  and  spread,  are 
smoothly  rolled  together  to  one  side.  An  extra  blanket 
and  a  couple  of  hot-water  bags  should  be  in  readiness 
in  case  of  emergency.  A  towel  is  hung  over  the  bed-rail, 
and  on  a  table  by  the  bed  are  placed  a  small  shallow  basin 
and  a  packet  of  gauze  sponges. 


Fig.  172. — Ether  bed  No.  2:  The  same,  with  the  bottom  elevated. 

Collapse. — In  cases  of  collapse  the  lower  end  of  the  bed 
is  generally  elevated.  As  this  emergency  is  always  liable 
to  occur,  many  hospitals  finish  the  preparation  of  the  ether 
bed  by  securing  a  firm  hair  pillow  upright  against  the  head 
railing.  A  draw-sheet  placed  over  the  pillow  and  pinned 
behind  the  bed-rail  keeps  the  pillow  in  position.  By  this 
arrangement  there  is  no  danger,  if  the  lower  end  of  the  bed  is 
raised,  of  the  patient's  head  slipping  through  the  rails. 


IMMEDIATE  CARE  AFTER  THE  OPERATION 

When  the  patient  is  returned  to  bed,  the  nurse  quickly 
ascertains  if  any  of  the  clothing  is  wet,  and  removes  it  if 
necessary.  The  blanket,  wanned  by  the  cans,  is  tucked 


IMMEDIATE   CARE  AFTER  THE  OPERATION 


571 


round  the  patient,  and  the  upper  covering  unrolled  and 
adjusted.  Except  in  special  conditions,  the  patient  is 
laid  flat  on  the  back,  with  the  head  carefully  turned  to  one 
side.  This  is  in  order  to  prevent  the  risk  of  vomited 
matter  falling  into  the  larynx  and  choking  him. 

It  is  a  rule  in  most  hospitals  that  no  hot- water  bags  may 
be  put  into  the  bed  of  an  unconscious  patient  without  a 
special  written  order.  If  hot-water  bags  are  ordered, 
they  must  be  hot  enough  to  give  the  warmth  for  which  they 
are  ordered,  and  are,  therefore,  hot  enough  to  burn  the 
patient  should  they  rest  against  the  skin.  To  prevent 
this,  first,  they  must  be  securely  covered;  second,  the 
patient's  body  must  be  protected  by  a  light  blanket, 
which  must  intervene  between  the  skin  and  the  hot-water 
bags;  third,  he  must  not  be  left  one  moment  alone  while 
the  hot-water  bags  are  in  his  bed. 

Once  in  bed,  the  patient  is  left  alone  with  his  nurse. 
The  room  should  be  warm,  between  70°  and  80°  F.  (un- 
less the  contrary  is  especially  ordered),  the  light  shaded,  and 
absolute  quiet  maintained.  Fresh  air  should  be  admitted 
freely,  avoiding  a  draught  on  the  patient.  No  unneces- 
sary talking  should  be  allowed,  and  visitors  and  avoidable 
coming  in  and  out  forbidden.  A  note  should  be  made 
on  the  record  chart  of  the  pulse,  respiration,  and  the  gen- 
eral condition  of  the  patient  immediately  on  his  return 
from  the  operating-room.  Thus: 


Time. 

11.15A.M. 


Temp. 


Pulse.     Resp 


110 


25 


Returned  from  oper- 
ating-room. Sweat- 
ing profusely. 

In  good  condition. 


However  slight  the  operation,  a  patient  must  not  be  left 
alone  until  he  is  fully  conscious  and  out  of  the  influence  of 
ether.  As  reaction  sets  in,  some  restlessness  is  sure  to  de- 
velop; the  patient  throws  himself  about  and  frequently 
tries  to  get  out  of  bed,  and  if  left  to  himself,  may  seriously 
injure  the  parts  freshly  operated  on,  strain  the  stitches, 
and  possibly  cause  a  hemorrhage.  As  consciousness  re- 
turns, vomiting  occurs.  If  the  nurse  is  not  at  hand  to 
keep  the  head  turned  to  one  side,  there  is  risk  that  the  vom- 


572  THE    CARE   OF   OPERATION   CASES 

ited  matter  may  fall  into  the  larynx  and  cause  fatal  as- 
phyxia. Further,  in  all  operations  there  is  risk  of  shock, 
the  first  symptom  of  which  must  be  appreciated.  In 
ward  cases  it  is  usual  to  isolate  major  operation  cases  for 
the  first  twenty-four  hours  after  the  operation,  most 
surgical  wards  having  a  room  or  rooms  reserved  for  the 
purpose.  If  the  construction  of  the  hospital  does  not 
admit  of  this  arrangement,  the  space  round  the  bed  should 
be  screened  off,  in  order  to  insure  as  little  disturbance  as 
possible. 

The  pulse  and  respiration  must  be  closely  watched. 
The  pulse  is  the  most  important  indication  of  the  patient's 
condition  after  any  operation.  Under  the  anesthetic 
both  pulse  and  respiration  become  considerably  raised; 
as  reaction  sets  in  the  pulse  should  become  steadily 
slower,  and  at  the  same  time  the  respirations  gradually 
return  to  normal.  A  good  pulse,  steadily  below  80,  is 
the  best  sign  that  the  patient  is  in  good  condition. 

Any  quickening  of  the  pulse  is  a  significant  symptom. 
It  may  be  due  to  an  attack  of  vomiting,  sudden  disturbance 
or  restlessness,  in  which  case  the  condition  is  only  tempor- 
ary. A  pulse  that  becomes  suddenly  soft,  small,  and  rapid, 
is  the  first  symptom  of  hemorrhage,  and  frequently,  to 
inexperienced  eyes,  there  may  be  no  other  symptom  of  the 
condition  (p.  595). 

The  first  twenty-four  hours  after  an  operation  is  com- 
monly one  of  extreme  wretchedness,  hardly  made  tolerable 
by  even  the  best  nursing.  Its  chief  symptoms  of  discom- 
fort are  restlessness,  nausea  and  vomiting,  and  thirst. 

Restlessness. — Many  surgeons  keep  their  patients 
under  the  influence  of  morphin  for  the  first  day,  and  fur- 
ther, if  circumstances  require  it.  Others,  however,  con- 
demn the  practice  as  further  upsetting  the  gastric  condi- 
tion, and  running  some  risk,  however  remote,  of  establish- 
ing a  habit. 

Where  it  is  essential  to  retain  a  fixed  position,  it  may  be 
necessary  to  restrain  the  movements  by  passing  a  sheet 
folded  lengthwise  over  the  lower  limbs  from  the  hips  to 
below  the  knees;  the  sheet  is  secured  with  safety-pins  to  the 
frame  of  the  bedstead.  A  second  sheet  may  be  necessary, 


IMMEDIATE    CAKE    AFTEK   THE    OPERATION          573 

fixed  in  the  same  way  across  the  chest,  but  leaving  the 
arms  free.  In  extreme  cases  ankle-straps  and  wrist-straps 
may  be  necessary.  All  these  restraints,  however,  naturally 
tend  to  increase  the  nervousness,  and  should  never  be 
kept  on  a  moment  longer  than  necessary. 

Where  the  position  may  be  changed,  it  is  comparatively 
easy  to  relieve  the  restlessness.  In  cases  of  abdominal 
section,  permission  is  frequently  given  to  mitigate  the 
enforced  recumbent  position  by  a  small  flat  pillow  placed 
under  the  small  of  the  back,  and  by  flexing  the  knees  over 
a  pillow.  The  latter  has  also  the  effect  of  relaxing  the 
abdominal  muscles,  and  so  relieving  tension  on  the 
stitches. 

Other  means  of  soothing  restlessness  are  sponging  the 
face  and  hands  with  hot  water,  gentle  massage  to  the  calves 
of  the  legs,  or  an  alcohol  rub  to  all  parts  of  the  body  that 
can  be  reached  without  moving  the  patient  from  the  pre- 
scribed position.  An  ice-bag  to  the  head  or  the  back  of  the 
neck  may  also  relieve  restlessness  and  induce  sleep, 
especially  if,  at  the  same  time,  a  hot-water  bag  is  placed 
at  the  feet.  This  treatment  should  not  be  used  unless 
the  condition  of  the  pulse  indicates  that  the  normal  con- 
dition of  the  circulation  is  reestablished. 

A  cause  of  restlessness  sometimes  overlooked  is  the  con- 
dition of  the  bladder.  Usually,  after  abdominal  section, 
an  hour  is  set  after  which,  if  the  patient  has  not  voided, 
the  catheter  is  passed.  This  is  usually  eight  hours  after 
the  operation  is  over.  In  some  cases,  however,  this  may 
be  too  long  to  wait,  and  to  empty  the  bladder  at  an  earlier 
hour  may  considerably  mitigate  the  restlessness. 

Nausea  and  Vomiting. — Some  nausea  and  vomiting 
almost  invariably  occurs  after  ether  (unless  with  children, 
who  frequently  escape),  and  to  a  less  extent  may  be  ex- 
pected after  chloroform.  After  nitrous  oxid  gas  there  is 
usually  no  vomiting. 

If  the  alimentary  tract  has  been  properly  prepared,  the 
vomitus  consists  of  a  little  greenish  fluid  with  a  bitter 
taste,  mixed  with  mucus  and  saliva.  During  the  act  of 
vomiting  an  unconscious  patient  must  have  his  head  turned 
forcibly  to  the  side  and  the  jaw  pushed  forward  and  up- 


574  THE   CARE   OF   OPERATION   CASES 

ward.  This  closes  the  epiglottis,  and  prevents  the  patient 
being  choked  by  the  vomitus  falling  into  the  larynx. 
The  mouth  is  cleansed  with  pieces  of  gauze,  either  dry  or 
soaked  in  water,  to  which  a  little  listerine  (or  other  mouth- 
wash)  may  be  added. 

After  operations  on  the  mouth,  throat,  nose,  etc.,  espe- 
cially such  operations  as  for  the  removal  of  adenoids  and 
tonsils,  a  quantity  of  blood  may  be  swallowed,  and  is 
usually  vomited  as  reaction  begins.  Many  throat  sur- 
geons encourage  vomiting  in  these  circumstances  by  order- 
ing the  patient  to  drink  water  freely  as  soon  as  he  is  con- 
scious. The  water  is  cold  or  iced,  in  order  not  to  encour- 
age bleeding  from  the  recent  wound. 

Some  hospitals  make  a  practice,  in  abdominal  operations, 
of  washing  out  the  stomach  before  the  patient  is  removed 
from  the  operating-table.  Warm  sterile  water  is  used, 
and  generally  one  to  two  ounces  of  castor  oil  is  introduced 
after  the  lavage  and  left  in  the  stomach. 

Where  there  is  much  retching,  there  is  some  risk  that 
stitches  about  the  abdomen  may  be  burst  by  the  strain. 
To  guard  against  this,  the  nurse  should  support  the  abdo- 
men during  the  attack  by  placing  her  hands  on  either 
side  and  pressing,  very  gently,  toward  the  incision. 

For  the  first  twelve  hours  little  treatment  is  ordered 
for  the  vomiting.  If  the  condition  does  not  improve  and 
the  vomiting  is  persistent,  treatment  becomes  necessary. 

Hot  stupes,  a  hot-water  bag,  or  a  mustard  plaster  may 
be  applied  to  the  epigastrium.  Cracked  ice  is  given  to 
suck,  though  this  has  the  disadvantage  of  increasing  the 
thirst.  Boiling  hot  water  in  sips  is  also  ordered.  Some 
doctors  wash  out  the  stomach  by  inducing  the  patient  to 
drink  a  couple  of  tumblers  of  warm  water,  in  each  of  which 
a  pinch  of  bicarbonate  of  soda  is  dissolved;  enough  is 
taken  to  induce  vomiting,  and  the  stomach  is  thus  washed 
out.  Lavage  may  also  be  ordered  in  the  usual  manner. 
Where  stimulants  are  permitted,  an  ounce  of  champagne 
or  half  an  ounce  of  brandy  may  be  poured  over  a  glass  of 
cracked  ice  and  given  in  sips. 

The  position  of  the  bed  may  also  be  a  help.  Usually 
it  is  best  to  keep  the  head  low  and  the  feet  elevated; 


ABDOMINAL   SECTION    OR   LAPAROTOMY  575 

if  vomiting  is  persistent,  the  reverse  may  be  tried,  and  is 
sometimes,  apparently,  successful. 

Drugs  that  may  be  ordered  to  check  vomiting  are: 
Cocain  hydrochlorid  (i  to  \  grain),  cerium  oxalate  (1  to  5 
grains),  bismuth  subnitrate  (5  to  15  grains),  and  others.  The 
bromids  are  sometimes  given  by  rectum  with  good  effect 
where  the  vomiting  is  due  to  the  nervous  condition. 
Hypodermoclysis,  or  intravenous  infusion  of  normal  salt 
solution,  also  has  frequently  the  indirect  effect  of  relieving 
the  condition. 

Thirst  after  an  anesthetic  is  the  symptom  most  trying 
to  the  average  patient.  It  is  chiefly  due  to  the  loss  of 
fluid  to  the  tissues  caused  by  the  necessary  hemorrhage, 
and  the  sweating  which  a  general  anesthetic  usually  causes, 
but  it  is  also  to  some  extent  the  result  of  the  irritation  of 
the  anesthetic. 

Fluid  may  be  restored  to  the  body  by  enemata  of  nor- 
mal salt  solution,  by  seepage,  or  constant  rectal  irrigation, 
by  hypodermoclysis,  and,  in  the  severer  cases  of  loss  of 
blood,  by  intravenous  infusion  of  normal  salt  solution. 

In  cases  other  than  abdominal  section  the  patient  is 
usually  allowed  to  satisfy  the  thirst.  Very  hot  water,  or 
hot  weak  tea,  allays  thirst  more  effectually  than  ice  or 
cold  drinks.  Cold  toast-water  is  often  agreeable,  and 
frequently  also  helps  to  check  the  vomiting. 

Where  the  operation  has  not  involved  any  part  of  the 
alimentary  tract,  the  ordinary  diet  is  usually  resumed  as 
soon  as  the  gastric  irritation  due  to  the  anesthesia  has 
subsided. 

ABDOMINAL  SECTION  OR  LAPAROTOMY 

Under  the  heading  of  abdominal  section  we  have  opera- 
tions on  any  of  the  important  organs  reached  by  opening 
the  abdominal  cavity;  in  other  words,  by  entering  the 
peritoneum,  the  most  important  closed  cavity  of  the  body. 
This  includes  operations  on  both  abdominal  and  pelvic 
organs;  on  the  intestines — for  hernia,  intussusception,  dis- 
eased appendix,  perforation,  or  ulcerated  conditions;  on 
the  liver  and  gall-bladder;  on  the  stomach;  on  the  pan- 
creas; on  the  uterus  and  its  appendages.  The  post-opera- 


576  THE   CARE   OF   OPERATION   CASES 

tive  care  of  cases  of  abdominal  sections  forms  the  larger 
part  of  a  modern  surgical  nurse's  work,  and  it  is  of  the  first 
importance  that  she  should  be  familiar  with  the  routine 
treatment  and  recognize  the  earliest  indications  of  un- 
toward symptoms.  While  special  conditions  call  for  some 
modification  of  the  treatment,  the  general  care  of  the 
patient  is  similar  in  the  large  majority  of  abdominal  sec- 
tions, and  to  mention  the  operations  separately  would,  in 
most  cases,  involve  needless  repetition.  The  diet  may  to 
some  extent  be  varied  with  the  different  cases,  especially  in 
operations  of  the  alimentary  tract,  but  on  this  point  the 
nurse  will  always  receive  definite  instructions. 

Position. — The  strict  recumbent  position  is  inforced  for 
a  specified  time.  Usually  each  doctor  has  his  own  method. 
Some  allow  the  patient  to  be  turned  for  a  short  period  on 
the  second  day;  others  keep  the  patient  flat  on  the  back 
for  a  longer  time.  The  extent  of  the  operation  and  the 
structures  involved  obviously  influence  the  treatment. 

The  return  to  an  upright  position  must  be  managed 
very  gradually.  One  pillow  is  usually  allowed  as  soon  as 
the  patient  is  out  of  ether,  provided  the  pulse  is  below 
80  and  regular.  A  second  is  added  for  the  daytime,  per- 
haps on  the  fourth  day,  if  the  condition  is  good;  later  a 
third  is  added  while  the  patient  is  taking  his  meals.  After 
the  stitches  are  removed  the  patient  is  propped  up  on  a 
bed-rest  at  intervals  and  is  gradually  accustomed  to  the 
upright  position. 

Doctors  differ  greatly  over  the  length  of  time  the  recum- 
bent position  should  be  inforced  and  the  time  the  patient 
must  remain  in  bed,  but  the  modern  tendency  is  generally 
in  favor  of  returning  to  normal  conditions  as  soon  as  pos- 
sible, provided  always  that  the  condition  of  the  heart  is 
good. 

The  period  of  the  strict  recumbent  position  is  the  time 
when  bed-sores  may  easily  form  (Chap.  I).  To  prevent  this 
the  bed  must  be  kept  smooth,  cool,  and  absolutely  dry. 
If  heat  or  pain  in  the  region  of  the  coccyx  is  complained  of, 
the  surgeon  should  be  notified,  and  permission  obtained, 
if  possible,  to  vary  the  position.  If  not,  it  may  be  per- 
mitted steadily  to  raise  the  pelvis  a  few  inches  from  the 


ABDOMINAL   SECTION    OH    LAPAROTOMY  577 

mattress  and  rub  the  spot  with  alcohol,  drying  it  off  with 
powder.  This  is  repeated  constantly.  To  raise  steadily, 
the  nurse  should  rest  her  elbow  on  the  bed  and  place  the 
palm  of  the  hand  flat  just  above  the  coccyx. 

The  scultetus  bandage,  still  in  common  use  in  abdominal 
surgery,  is  a  prolific  source  of  bed-sores.  The  lower  mar- 
gin becomes  creased,  soiled,  or  damp  from  perspiration,  and 
if  the  nurse  has  orders  not  to  move  the  bandage  or  turn 
the  patient,  a  bed-sore  may  be  extremely  difficult  to  avoid. 
In  many  hospitals  the  scultetus  bandage  is  replaced  by 
strips  of  adhesive  strapping,  to  one  end  of  which  tapes 
are  sewn  (p.  327).  If  a  scultetus  bandage  is  also  used,  it 
may  then  be  changed  or  readjusted  without  danger  of  dis- 
turbing the  dressings. 

Drainage. — In  operations  on  the  bladder  and  in  many  on 
the  gall-bladder  drainage  may  be  necessary,  sometimes  for 
a  considerable  time.  To  keep  the  bed  dry  and  the  patient 
comfortable,  a  bottle  or  jar  may  be  attached  to  the  bed- 
frame;  in  this  is  introduced  a  length  of  rubber  tubing 
connected  by  a  short  glass  tube  with  the  catheter  (bladder) 
or  drainage-tube  (gall-bladder)  inserted  at  the  site  of 
operation.  The  vessel  should  be  of  glass,  so  that  the  con- 
tents may  be  seen.  A  strip  of  adhesive  strapping  attached 
to  the  outside  of  the  bottle  may  be  marked  off  in  gradua- 
tions, and  forms  a  better  guide  than  the  eye  of  the  amount 
passed  from  hour  to  hour.  If  the  fluid  is  not  flowing,  the 
cause  is  usually  a  clot  that  has  lodged  in  the  tube.  The 
lower  tube  should  be  disconnected  and  irrigated  under  the 
water-tap;  if  no  impediment  is  found,  the  surgeon  must 
be  notified,  as  it  then  becomes  necessary  either  to  irrigate 
or  remove  the  stationary  tube.  In  order  that  a  stoppage 
may  be  at  once  detected,  the  nurse  should  make  a  prac- 
tice of  examining  the  bottle  at  regular  intervals. 

Diet. — After  an  abdominal  section  it  is  necessary  to 
keep  the  intestines  at  rest,  so  that  the  parts  operated  on 
may  be  undisturbed.  Nothing,  therefore,  that  may  excite 
peristalsis  or  lead  to  the  formation  of  gas  must  be  given  for 
a  specified  time. 

The  usual  treatment  is,  after  six  hours,  to  give  every 
hour  teaspoon  doses  of  boiling  hot  water;  after  twelve 
37 


578        THE  CARE  OF  OPERATION  CASES 

hours,  the  amount  is  gradually  increased.  Patients  fre- 
quently find  it  a  relief  to  suck  pieces  of  gauze  soaked  in 
lemon-juice  and  water.  Some  surgeons  feed  their  patients 
entirely  by  enemata  for  the  first  forty-eight  hours,  and 
longer  if  nausea  persists.  Beef  peptones,  broth,  meat- 
juice,  raw  egg  and  milk  are  administered  in  this  way,  and, 
if  necessary,  a  stimulant  is  added.  The  enema  should 
not  exceed  six  ounces,  and  may  be  repeated  every  eight 
hours. 

After  twenty-four  hours  fluid  nourishment  is  begun  in 
small  amounts.  Albumin-water,  liquid  peptones,  strained 
chicken  or  beef-tea,  or,  more  rarely,  milk,  are  given,  be- 
ginning usually  with  half  an  ounce  at  a  time,  until  it  is 
seen  what  the  stomach  will  retain.  In  operations  on 
the  digestive  organs  a  longer  period  of  starvation  may  be 
necessary.  A  restricted  liquid  diet  is  given  until  the 
bowels  have  moved,  after  which  a  soft  diet  is  ordered,  to 
which,  gradually,  solids  are  added,  avoiding  coarse  vege- 
tables and  seasoned  or  fried  dishes.  While  on  a  liquid 
diet,  and  until  the  patient  can  use  a  tooth-brush,  the  mouth 
must  be  carefully  cleansed  at  regular  intervals  (Chap.  I.) 

Bowel  Movements. — It  is  usual  to  induce  an  action  of 
the  bowels  at  the  beginning  of  the  third  day  after  the 
operation:  that  is,  at  the  end  of  the  first  forty-eight  hours. 
Frequently  a  course  of  calomel  is  given,  beginning  twenty- 
four  hours  after  the  operation,  followed  by  salts  on  the 
following  morning;  or  a  suds  enema  may  be  prescribed 
on  the  second  morning  after  the  operation.  The  nurse 
should  always  be  able  to  report  whether  or  not  flatus  has 
been  passed  by  rectum,  since  this  is  an  important  indica- 
tion of  the  condition  of  the  intestines. 

To  induce  a  regular  daily  evacuation  of  the  bowels  is 
of  the  first  importance,  both  during  the  critical  period  of 
nursing  and  throughout  convalescence.  When  the  period 
of  strict  starvation  is  over,  the  diet  should  be  chosen  to 
further  this  end.  Raw  fruit-juice  in  the  early  morning, 
meat  extracts,  thin  oatmeal  gruel,  cream,  all  help  and  are 
usually  preferred  to  milk,  which  in  many  patients  produces 
constipation.  If  milk  is  given,  it  should  be  diluted  or  given 
in  such  form  as  junket,  with  cream,  etc.  (Chap.  XXII). 


ABDOMINAL   SECTION   OR    LAPAROTOMY  579 

The  evacuations  should  be  inspected,  and  in  the  case  of 
operations  involving  any  part  of  the  alimentary  tract, 
should  be  especially  examined  for  any  appearance  of 
blood. 

Visitors. — It  should  be  remembered  that  a  major 
operation  must  always  produce  some  nervous  strain,  of 
which,  while  the  patient  is  lying  quietly  in  bed,  there  may 
be  but  little  symptom.  If  the  regulation  of  visitors  is 
left  to  the  nurse  she  should  proceed  very  cautiously, 
noticing  carefully  the  effect  on  her  patient,  and  erring 
rather  in  keeping  the  patient  too  quiet  than  in  risking 
excitement  for  which  the  patient  may  pay  later.  Usually 
the  nearest  relation  is  admitted  for  a  short  time  on  the 
third  day,  all  being  well,  and  one  visitor  a  day  only 
allowed,  for  a  specified  time,  until  the  patient  is  sitting 
up  in  bed.  It  is  always  wisest  to  get  definite  instruction 
from  the  surgeon  on  this  point. 

Distention. — An  untoward  symptom  of  grave  import 
in  the  nursing  of  abdominal  sections  is  distention,  or 
inflation  of  the  intestines  with  gas.  The  condition  is 
caused  by  intestinal  obstruction;  commonly  it  is  a  tem- 
porary (though  serious)  condition,  due  to  gastric  upset 
from  the  anesthetic,  but  occasionally  complete  obstruction 
may  be  present,  caused  by  accidental  twisting  or  other 
injury  to  a  coil  of  intestine. 

The  nurse  must  be  on  the  watch  for  the  first  symptoms 
of  tightening  of  the  bandage  at  the  upper  margin.  The 
abdomen  is  swollen  and  more  or  less  rigid,  and  the  breath- 
ing shallow;  no  flatus  is  passed.  The  condition  usually 
occurs  early,  during  the  day  of  the  operation  or  the  day 
after.  At  this  time  the  patient's  temperature  is  easily 
upset,  and  will  probably  rise  together  with  the  pulse, 
whether  the  condition  is  due  to  gastritis  or  to  complete 
obstruction.  If  due  to  the  latter,  the  physical  symptoms 
will  be  intensified  and  the  vomitus  will  probably  become 
stercoraceous  (p.  713),  always  a  very  serious  symptom. 

To  relieve  distention  hot  turpentine  stupes  may  be 
applied  to  the  abdomen  and  changed  repeatedly,  and  the 
rectal  tube  be  passed  as  high  as  possible  up  the  colon.  A 
hot  suds  enema  may  give  relief  (unless  in  operations  on  the 


580  THE   CARE   OF   OPERATION   CASES 

lower  bowel),  or  medicated  enemata  containing  either 
milk  of  asafetida,  alum  (carminatives),  sulphate  of  magne- 
sia, or  castor  oil  (Chap.  IV).  All  nourishment  is,  of  course, 
stopped;  the  mouth  should  be  washed  out  frequently. 

Drugs  that  may  be  ordered  by  mouth  are  asafetida 
(tincture  of,  5  to  20  minims),  turpentine  (5  to  10  minims, 
in  capsule),  and  eserin,  usually  given  by  hypodermic 
Oro"  to  rs  grain).  The  two  former  have  a  carminative 
action;  eserin  has  the  property  of  stimulating  the  peris- 
taltic action. 

If  there  is  stercoraceous  vomiting,  the  stomach  is  usually 
washed  out  with  plain  sterile  water,  and  nothing  is  given 
by  mouth.  When  entire  intestinal  obstruction  is  present, 
a  second  operation  will  probably  be  necessary. 

Still  more  serious  is  the  true  tympanites,  when  the 
peritoneal  cavity  becomes  distended  with  gas.  The  con- 
dition is  seen  in  general  peritonitis,  a  complication  which, 
if  occurring  after  an  abdominal  operation,  is  almost 
always  fatal.  It  may  be  caused  by  infection  at  the  time 
of  operation,  or  may  be  due  to  accident,  such  as  a  decom- 
posing blood-clot  in  the  cavity,  or  the  escape  of  the  intes- 
tinal contents  into  the  cavity  from  a  perforation.  This 
form  of  distention  occurs  usually  later  than  the  third  day. 
The  temperature  will  probably  be  high,  and  the  pulse 
quick,  hard,  and  wiry;  as  the  condition  advances  the  feat- 
ures are  pinched  and  anxious,  and  the  patient  is  frequently 
delirious.  The  bowels  are  constipated,  or  there  may  be 
total  obstruction.  The  appearance  of  the  distention  and 
the  characteristic  hard,  wiry  pulse  are  the  most  easily 
recognized  diagnostic  points.  In  intestinal  distention  the 
swollen  bowel  may  be  felt  through  the  abdominal  wall, 
unless  the  wall  is  unusually  thick;  in  peritoneal  distention 
there  is  a  tense,  drum-like  swelling  of  the  entire  abdomen, 
which  is  absolutely  rigid  and  tender  to  the  touch.  The 
chief  hope  of  recovery  lies  in  very  early  recognition  of  the 
condition.  The  cavity  is  usually  opened,  the  peritoneum 
irrigated,  and  drainage  established.  Turpentine  stupes, 
sprinkled  with  laudanum,  may  relieve  the  rigidity  and 
allay  pain. 

Many  surgeons  have  an  elaborate  schedule  for  the  post- 


ABDOMINAL    SECTION   OR   LAPAROTOMY  581 

operative  nursing  of  their  cases.  These  are  a  great  help 
to  the  nurse,  who  then  knows  exactly  what  she  is  expected 
to  do  at  given  intervals  and  in  special  circumstances. 
At  the  same  time  a  very  little  experience  will  show  the 
nurse  that  each  patient  is  a  fresh  proposition,  and  that 
rigidly  iron  rules  may  defeat  their  own  object. 

There  are  three  complications  to  be  dreaded  and  guarded 
against  in  all  operations — shock,  hemorrhage,  and  sepsis. 

Shock. — Early  shock  is  shown  by  rapid,  small,  feeble 
pulse,  pallor,  cold  extremities,  prolonged  unconsciousness, 
profuse  sweating,  and,  usually,  subnormal  temperature. 
If  the  condition  is  not  promptly  treated,  the  life  may  be 
lost. 

The  usual  treatment  consists  in  the  application  of  exter- 
nal heat  (blankets  and  hot- water  bags),  in  raising  the  bot- 
tom of  the  bed  so  that  the  head  is  lower  than  the  feet,  in 
order  to  flush  the  vital  centers,  and  in  hypodermoclysis  of 
hot  normal  salt  solution  (500  c.c.).  Enemata  of  hot  nor- 
mal salt  solution,  black  coffee,  or  brandy  may  be  ordered, 
and  cardiac  stimulants  are  given  by  hypodermic  injection. 
Those  most  commonly  ordered  are  atropin  sulphate  (TSTF 
to  TTff  grain),  strychnin  sulphate  (-j-g-  to  yV  grain),  and  oil 
of  camphor  (3  to  5  minims). 

Later  shock  is  evinced  by  heightened  temperature, 
restlessness  or  marked  prostration,  delirium,  and  often  by 
prolonged  nausea  and  vomiting.  The  general  treatment 
consists  in  maintaining  absolute  rest  and  quiet  and  in 
nursing  up  the  patient's  strength.  Usually  the  bottom  of 
the  bed  is  raised  to  keep  the  head  low,  but  in  some  instances 
this  appears  to  increase  the  vomiting,  and  the  orders  may 
be  to  raise  the  head  of  the  bed  instead.  Hypodermoclysis 
may  be  ordered  daily  or  twice  a  day,  and  stimulants  will 
probably  be  given.  Digitalis  is  usually  preferred  (tincture, 
5  to  10  minims),  as  it  is  a  tonic  to  the  heart,  and  brandy, 
whisky,  or  champagne  may  be  ordered.  The  diet  should 
be  as  nourishing  as  the  state  of  the  digestion  permits.  If 
nausea  is  persistent,  the  nourishment  is  given  by  rectum. 
(See  also  Chap.  XVII.) 

Hemorrhage. — No  nurse  should  be  left  alone  with  an 
operation  case  until  she  is  perfectly  familiar  with  the  first 


582  THE    CARE   OF   OPERATION   CASES 

symptoms  of  hemorrhage,  since  the  life  depends  on  the 
early  recognition  of  the  condition. 

Hemorrhage  is  either  external  or  internal.  If  the  hemor- 
rhage is  external,  a  patch  of  bright  blood  may  be  seen 
on  the  dressing,  quickly  increasing  in  size.  Where  the 
patient  is  lying  on  his  back,  it  must  be  remembered  the 
blood  will  have  a  tendency  to  trickle  under  the  dressing 
to  the  lowest  point  possible,  and  the  bandage  on  which 
the  patient  is  lying  may  be  soaked  through,  while  there 
may  be  no  sign  apparent  on  the  dressing  immediately  over 
the  incision.  In  abdominal  surgery  hemorrhage  is  prac- 
tically always  internal,  and  the  physical  symptoms  will 
be  the  only  guide  to  this  very  grave  condition. 

As  has  already  been  said,  the  pulse  is  the  most 
important  indication  of  a  patient's  condition  after  an 
operation,  and  any  change  is  significant.  The  first  physical 
symptom  of  hemorrhage  is  a  steady  quickening  of  the 
pulse,  which  also  becomes  soft  and  small;  accompanying 
symptoms  are  pallor,  syncope,  clammy  skin,  usually 
(but  not  invariably)  subnormal  temperature,  and  the  con- 
dition known  as  air-hunger,  in  which  the  patient  fights  and 
gasps  for  air.  Later  the  patient  becomes  cyanosed,  which 
is  especially  apparent  round  the  mouth  and  under  the 
nails. 

Not  a  moment  must  be  lost  in  summoning  the  surgeon. 
If  the  bleeding  is  external,  compression  of  the  nearest 
digital  point  must  be  made  meanwhile  (p.  597).  In 
hospital  work  the  nurse's  responsibility  extends  no  further. 
The  treatment  consists  in  placing  the  patient  at  once  on 
the  operating-table,  reopening  the  incision,  and  ligating 
the  bleeding  spot.  The  cavity  is  then  usually  irrigated 
with  sterile  water  or  normal  salt  solution  in  order 
thoroughly  to  remove  the  blood-clots,  which,  if  left  in 
the  cavity,  would  decompose. 

If  there  is  any  delay,  the  bottom  of  the  bed  is  raised,  a 
light  ice-bag  may  be  applied  over  the  area,  and  usually  a 
dose  of  morphin  is  given  at  once  (i  to  i  grain).  Stimulants 
are  not  given,  as  by  quickening  the  heart's  action  they 
would  increase  the  hemorrhage,  and  even  water  must  be 
withheld.  Fresh  air  should  be  admitted  freely. 


ABDOMINAL   SECTION    OR   LAPAROTOMY  583 

When  the  patient  is  returned  to  bed,  hypodermoclysis  of 
normal  salt  solution  is  usually  given  to  restore  to  the  circu- 
lation the  fluid  lost,  or  the  fluid  may  be  injected  directly 
into  a  vein  (p.  519).  The  patient  is  nursed  with  the  head 
low  until  the  pulse  is  normal.  After  a  severe  hemorrhage 
the  pulse  is  markedly  subnormal  and  may  be  reduced  to 
40  per  minute.  Severe  thirst  is  a  characteristic  symptom, 
and  is  usually  treated  with  rectal  injection  of  normal  salt 
solution  and  washing  out  the  mouth  with  lemon-juice  and 
water.  With  external  hemorrhage,  of  course,  thirst  may 
be  quenched  by  drinking.  (See  also  Chap.  XVII.) 

Sepsis. — After  a  clean  operation  sepsis  occurs  only  as 
the  result  of  carelessness.  The  sources  and  channels  of 
infection  have  been  pointed  out  in  the  chapter  on  Technic, 
and  it  will  be  remembered  that  the  whole  aim  and  end  of 
surgical  technic  is  the  prevention  of  infection. 

The  first  general  symptoms  of  sepsis  are  malaise, 
shivering,  and  a  rise  of  temperature.  The  importance 
of  shivering  as  a  symptom  should  be  realized.  In  a  few 
cases  it  may  be  due  to  a  nervous  condition  only,  which 
may  or  may  not  be  sufficient  to  upset  the  temperature. 
An  attack  of  shivering  followed  by  a  rise  of  temperature 
is  the  most  characteristic  symptom  of  the  invasion  of  the 
body  by  an  infection,  whether  local  or  general.  (Rigors, 
p.  719.) 

Other  causes  may  result  in  rise  of  temperature.  Thus, 
a  temperature  on  the  day  of  operation  is  generally  of 
nervous  origin;  on  the  second  day  it  may  be  caused  by 
a  temporary  condition,  such  as  constipation  or  want  of 
rest.  The  organisms  which  produce  the  phenomenon  of 
sepsis  take  about  three  days  to  develop  in  the  human 
body,  therefore  a  rise  of  temperature  on  the  third  day, 
especially  if  preceded  by  shivering,  is  always  looked  on 
with  suspicion.  The  local  symptoms  of  sepsis  are  red- 
ness and  tension  in  the  region  of  the  incision,  and  the 
formation  of  pus. 

The  treatment  varies  somewhat  with  the  nature  of  the 
operation.  Frequently  the  incision  is  opened,  the  cavity 
cleaned  with  antiseptics,  and  drainage  established,  after 
which,  if  the  disturbance  is  local,  the  temperature  may 


584  THE   CARE    OF   OPERATION    CASES 

drop  and  recovery  result  without  further  disturbance. 
A  general  septic  condition  is  characterized  by  fever,  either 
remittent  or  intermittent,  rigors,  prostration,  rapid  emacia- 
tion, the  formation  of  secondary  abscesses,  and  a  tendency 
to  bed-sores;  in  many  cases  it  proves  fatal. 

The  treatment  is  directed  locally  toward  free  drainage 
and  the  use  of  antiseptics,  and  generally  toward  building 
up  the  strength  with  a  nourishing  diet  and  a  generous 
use  of  stimulants.  In  extreme  cases  the  patient  is  best 
nursed  on  a  water-  or  air-bed,  in  order  to  counteract  the 
tendency  to  bed-sores. 

Sepsis  occurring  in  the  second  week  is  usually  due  to 
infection  from  the  catgut.  On  opening  the  wound  a  small 
pocket  of  pus  is  discovered;  after  this  is  evacuated  the 
symptoms  commonly  subside.  Recovery  is,  however, 
delayed,  since  healing  must  now  take  place  partly  by 
granulation  instead  of  entirely  by  first  intention. 

In  common  with  all  wounds,  operation  wounds  may 
become  channels  of  certain  special  infections,  of  which  the 
most  important  are  erysipelas,  scarlet  fever,  and  tetanus. 
(See  Chap.  XVIII.) 

The  above  dangers  are  common  to  all  operations.  In 
surgery  on  special  organs  special  conditions  may  arise,  and 
in  the  nursing  special  details  must  be  observed. 

EYE  OPERATIONS 

An  old-fashioned  book  on  nursing  opens  one  of  its 
chapters  with  the  words  "  no  selfish  or  unconscientious 
woman  should  be  given  charge  of  a  case  of  tracheotomy." 
Even  more  emphatically  one  might  use  the  words  in  con- 
nection with  the  nursing  of  eye  cases.  Above  all  other 
kinds  of  nursing,  success  depends  on  the  conscientious 
attention  to  small  details,  and  failure  may  mean  the  loss 
to  the  patient  of  his  most  precious  possession,  since  noth- 
ing can  replace  the  sight. 

Operations  on  the  eye  are  usually  done  under  a  local 
anesthetic,  to  avoid  the  restlessness,  nausea,  vomiting, 
and  uncontrolled  movements  following  etherization. 
Frequently  the  patient  remains  in  his  own  bed  in  order 
to  avoid  the  movements  in  taking  him  to  and  fro.  The 


EYE    OPERATIONS  585 

preparation  (p.  476)  must  be  thoroughly  performed, 
and  will  for  most  operations  include  the  dilatation  of 
the  pupil  with  atropin.  The  head  is  placed  so  that 
the  eye  on  which  the  operation  is  to  be  performed  is  in 
the  best  light.  The  hair  is  covered  with  a  sterile  towel 
and  the  sterile  area  arranged  as  in  other  operations.  The 
requirements,  besides  the  sterile  instruments  and  an  eye 
lens  (also  sterile),  are  very  simple.  A  packet  of  gauze 
sponges,  a  couple  of  eye-pads  and  a  bandage,  a  douche  of 
warm  boric  lotion,  2  per  cent.,  and  small  quantities 
(about  2  drams)  of  the  special  eye-drops,  freshly  prepared, 
in  small  sterile  bottles  with  sterile  droppers.  The  bottles 
contain  cocain  hydrochlorid  the  required  strength  for  the 
local  anesthetic  (usually  2  per  cent.),  atropin  sulphate 
(2  to  4  grains  to  the  ounce,  mydriatic),  and  eserin  (1  grain 
to  the  ounce,  my  otic). 

After  the  operation  both  eyes  are  closed  and  bandaged 
for  at  least  the  first  twenty-four  hours,  and,  as  a  rule,  a 
fixed  position  is  enforced.  The  room  is  darkened,  special 
care  being  taken  to  prevent  streaks  of  light  from  an  open 
door  or  from  a  badly  fitting  blind;  these  are  more  irritating 
than  a  brighter  light  well  diffused. 

The  dangers  of  the  next  twenty-four  hours  are,  first, 
restless  movements  which  may  result  in  hemorrhage  from 
the  recent  incision,  and,  second,  that  the  patient  may  rub 
the  eyes  or  put  his  fingers  under  the  bandage.  To  rub 
the  eyes  if  they  are  irritated  is  an  almost  uncontrollable 
impulse,  and  a  patient  may  do  it  unconsciously  if  not 
closely  watched.  Not  only  is  the  wound  irritated,  but 
there  is  the  greatest  risk  that  it  may  in  this  manner  become 
infected  and  the  sight  lost. 

If  the  patient  is  quiet  and  the  pulse  steady,  all  is  well. 
Pain  is  a  symptom  that  should  be  at  once  reported. 
Usually  a  surgeon  will  leave  definite  orders  to  be  followed 
if  pain  arises.  Commonly,  1  or  2  drops  of  atropin  are 
dropped  into  the  eye  and  compresses  of  sterile  boric 
lotion  (2  per  cent.)  are  applied  continuously.  These  may 
be  hot  or  ice  cold.  (See  Eye  Applications.)  The  pain  may 
be  the  result  of  a  hemorrhage  or  may  signify  the  beginning 
of  inflammation,  both  of  which  conditions  may  be  checked 


586  THE   CARE   OF   OPERATION   CASES 

by  prompt  treatment.  Another  remedy  used  in  eye  sur- 
gery for  the  relief  of  pain  due  to  inflammation  is  the  appli- 
cation of  leeches  to  the  temple  (p.  145). 

For  the  first  twenty-four  hours  a  nurse  will  require  all 
her  tact,  patience,  and  vigilance.  The  patient  must  be 
fed  in  the  recumbent  position  and  must  use  the  bed-pan. 
Even  in  sleep  he  must  be  closely  watched,  since  then  his 
movements  are  least  under  control.  The  nurse  in  charge 
should  not  leave  the  bedside  unless  some  responsible 
person  can  take  her  place.  Usually  after  twenty-four 
hours  the  dressing  is  changed,  after  which  some  move- 
ment is  allowed  and  the  sound  eye  is  unbandaged.  The 
affected  eye  should  look  clear,  the  pupil  well  dilated.  If 
there  is  no  inflammation  the  most  responsible  time  of 
nursing  is  over,  and  the  patient's  own  common  sense  may 
be  to  some  extent  trusted. 

Eye  surgeons  differ  in  the  time  necessary  to  keep  the 
patient  lying  down  or  in  bed  after  their  operations,  and 
young  nurses  are  inclined  to  think  lightly  of  strict  rules 
in  consequence.  This  is  a  mistake.  Each  step  of  a 
treatment  is  part  of  a  whole;  what  is  not  necessary  for 
one  process  may  be  essential  in  another. 

If  infection  takes  place  the  sight  will  almost  inevitably 
be  lost.  Leeches  are  usually  ordered  and  constant  com- 
presses, which  must  be  applied  without  intermission  under 
strict  aseptic  precautions.  The  patient's  strength  is  kept 
up  with  nourishing  diet,  commonly  some  preparation  of 
iron  is  ordered.  If  a  stimulant  is  required,  strychnin 
is  ordered  in  preference  to  the  alcoholic  stimulants. 

TRACHEOTOMY 

Another  operation  case  requiring  special  vigilance  in 
the  nursing  is  tracheotomy.  The  operation  consists  of 
an  incision  into  the  windpipe  and  the  insertion  of  a  tube, 
through  which  the  patient  can  breathe.  It  is  necessary 
in  conditions  where,  from  false  growths,  foreign  bodies, 
or  injury,  breathing  is  obstructed  at  a  point  above  the 
incision.  Before  the  introduction  of  intubation,  trache- 
otomy was  a  common  treatment  in  diphtheria,  and  often 


TRACHEOTOMY  587 

had  to  be  carried  out  as  an  emergency  procedure  with 
whatever  instruments  were  at  hand. 

In  performing  the  operation  the  throat  is  exposed  by 
bending  the  head  back  over  a  small  sand-bag.  When  the 
windpipe  is  first  opened  there  is  a  rush  of  air  and  blood- 


Fig.  173. — Position  of  patient   for  laryngotomy  and  tracheotomy 

(Morrow). 

streaked  mucus  and  a  considerable  amount  of  coughing, 
which  is  -allowed  to  subside  before  the  tube  is  inserted. 
A  special  dilator  is  used  to  hold  the  incision  well  open. 
At  first  a  double  silver  tube  is  used,  the  object  being  that 
if  the  tube  becomes  blocked  with  mucus  the  inner  tube 


Fig.  174. — Tracheotomy  tube  (Morrow). 

is  easily  removed  and  cleaned,  whereas  if  the  entire  tube 
is  taken  out  it  is  often  difficult  to  replace,  and  asphyxia 
may  result.  Later  a  single  tube  of  either  hard  or  soft 
rubber  is  substituted. 

The  tube  is  kept  in  place  by  narrow  tape.     The  best 


588  THE    CARE    OF    OPERATION    CASES 

method  of  threading  is  to  thread  both  ends  of  a  piece  a 
yard  long  through  the  holes  in  the  plate;  the  loop  thus 
formed  is  passed  over  the  head  and  the  ends  are  then 
brought  behind  and  tied  in  a  bow.  A  small  dressing  of  soft 
sterile  gauze  cut  to  fit  round  the  tube  is  placed  between 
the  plate  of  the  tube  and  the  skin. 

The  air  breathed  is  taken  directly  into  the  lungs  without 
becoming  warmed  and  moistened,  as  when  drawn  through 
the  air  passages.  At  first,  therefore,  the  air  must  be  arti- 
ficially warmed  and  moistened.  To  this  end  the  bed  is 


Fig.  175. — Showing  the  tracheotomy  tube  in  place  (Stoney). 

screened  and  a  croup  kettle  is  kept  going,  with  the  spout 
directed  into  the  screened  area  (p.  366). 

Feathers  washed  in  soap  and  water  and  sterilized  in  the 
autoclave  are  kept  soaking  in  an  alkaline  solution,  such 
as  bicarbonate  of  soda,  and  used  to  clean  the  interior  of 
the  tube.  When  a  single  tube  is  used  this  is  done  with 
the  tube  in  place,  with  the  double  tube  the  inner  tube  is 
removed,  cleaned,  and  replaced. 

Constant  watchfulness  is  necessary  to  prevent  the  tube 
becoming  blocked,  especially  where  there  is  much  secretion 
from  the  lungs  or  bronchial  tubes.  If  the  single  tube  be- 
comes totally  blocked,  so  that  no  air  can  pass  and  the 


INTUBATION 


589 


patient  is  in  danger  of  becoming  asphyxiated,  the  tube  is 
entirely  removed  and  the  incision  held  open  with  the 
dilator  till  assistance  is  obtained. 

When  the  tube  is  finally  removed  the  patient  must  also 
be  closely  watched  until  normal  breathing  is  reestablished. 
Some  patients  take  a  long  time  to  accustom  themselves 
to  breathing  again  in  the  natural  way. 

INTUBATION 

Intubation  has,  in  the  majority  of  cases,  superseded  the 
operation  of  tracheotomy.  This  is  the  introduction  of  a 


Fig.  176. — O'Dwyer  intubation  instruments:  1,  Tube  with  obtu- 
rator in  place;  2,  tube  and  obturator  separated;  3,  gage;  4,  mouth- 
gag;  5,  introducer;  6,  silk  thread;  7,  extractor  (Morrow). 

metal  tube  made  to  fit  into  the  larynx  and  upper  part  of 
the  trachea,  so  that  the  necessary  opening  is  preserved  in 
spite  of  inflammatory  processes  or  swollen  tissues. 


590 


THE   CARE   OF   OPERATION   CASES 


The  patient  is  held  in  an  upright  position  directly  oppo- 
site the  operator,  the  head  bent  a  little  back,  the  chin  in  a 
straight  line  with  the  trachea.  The  mouth  is  opened  and 
fixed  with  a  gag.  The  tongue  is  depressed  so  as  to  expose 
the  epiglottis  and  upper  end  of  the  trachea.  The  tube 
into  which  is  inserted  the  obturator  is  held  by  an  intro- 
ducer and  slipped  into  the  larynx,  directly  in  front  of  the 
little  leaf-shaped  epiglottis.  When  it  is  in  place  the  in- 
troducer and  obturator  are  withdrawn.  Where  the  throat 


Fig.   177. — Intubation,  introducing  the  tube    into  the   patient's 
mouth  (Morrow). 

is  roomy  and  the  tissues  are  not  swollen  or  inflamed,  the 
process  is  comparatively  easy;  where  there  is  much  in- 
flammation, with  copious  discharge  and  impeded  breathing, 
it  is  an  operation  requiring  skill  and  experience.  If  the 
tube  does  not  slip  into  the  trachea  it  may  be  accidentally 
deposited  in  the  esophagus,  where  it  will  be  readily  swal- 
lowed. To  prevent  this  loss  a  long  strand  of  silk  or  stout 
linen  is  threaded  through  a  perforation  in  the  tube,  by 
which  the  tube  can  be  withdrawn  if  it  is  not  in  the  right 
place.  This  thread  may  be  left  in  place,  the  free  end  being 


INTUBATION  591 

brought  outside  the  mouth  over  the  patient's  ear,  and  fixed 
by  a  piece  of  adhesive  strapping  behind  the  ear.  The  ad- 
vantage of  this  is  that  should  the  tube  be  coughed  out 
of  the  larynx  the  thread  will  prevent  its  being  swallowed. 
The  tube  can  also  be  removed  by  gentle  traction  on  the 
thread.  If  there  is  no  thread,  a  special  instrument  known 
as  an  extractor  (Fig.  176,  7)  is  used  to  remove  the  tube. 

Every  variety  of  operation  brings  with  it  some  special 
details  in  the  nursing,  and  the  difference  between  an  un- 
successful and  a  good  nurse  is  often  just  in  the  care  which 
she  gives  to  these  various  details.  Thus,  in  operations  on 
the  extremities,  the  joints,  or  the  bones,  the  physical  con- 
dition is  comparatively  unimportant,  but  the  success  of 
the  operation  may  lie  entirely  in  the  strict  maintenance  of 
a  certain  position,  with  the  resulting  difference  between 
permanent  lameness  or  cure.  In  operations  about  the 
head,  especially  where  the  brain  has  been  exposed,  as  in 
trephining  from  any  cause,  quiet  is  almost  the  most  essen- 
tial part  of  the  treatment,  and  the  light  should  always  be 
shaded.  In  amputation  cases  there  is  a  certain  amount 
of  risk  of  hemorrhage  from  the  slipping  of  a  ligature, 
either  from  abrupt  movements  or  from  the  reestablished 
circulation  as  reaction  sets  in.  This  is  especially  to  be 
dreaded  in  amputation  of  the  femur,  where  bleeding  from 
the  femoral  artery  might  be  fatal  in  a  short  time.  In 
these  cases,  therefore,  we  watch  the  pulse  especially 
closely,  and  until  all  danger  is  past  we  keep  a  tourniquet 
at  hand,  which  can  be  quickly  adjusted.  Here  again  we 
must  remember  not  to  rely  on  the  outward  sign  of  hemor- 
rhage, since  from  the  patient's  position  the  blood  will 
probably  run  underneath  the  dressings  to  the  bed  before 
there  is  any  appearance  of  blood  on  the  top  of  the  dressing. 

Only  long  experience  can  teach  a  nurse  all  she  should 
know  of  the  nursing  of  operation  cases.  But  at  least  we 
should  see  that  the  essential  details  are  carefully  explained 
to  her  and  the  principal  dangers  and  difficulties  pointed 
out. 


CHAPTER  XVII 
NURSING  IN  ACCIDENTS  AND  EMERGENCIES 

Shock — Hemorrhage:  Varieties;  Methods  of  Arrest — Pressure, 
Styptics,  Ligatures,  Torsion;  Treatment  of  Physical  Condition; 
Special  Hemorrhages:  External,  Subcutaneous,  Internal,  Revealed, 
Concealed;  Enterorrhagia ;  Hematemesis;  Hemoptysis;  Epistaxis: 
From  the  Throat;  From  the  Ear;  Antepartum  Hemorrhage;  Post- 
partum  Hemorrhage;  Hemorrhage  from  a  Ruptured  Tube;  Hemor- 
rhage in  Purpura,  Scurvy,  Bleeder's  Disease;  Perforation. 

SHOCK 

SHOCK  is  a  profound  general  prostration  or  loss  of  vital- 
ity brought  about  by  the  effect  on  the  nervous  system  of 
severe  or  violent  physical  strain,  such  as  an  operation  or 
an  accident,  or,  more  rarely,  by  violent  mental  emotion, 
particularly  fear.  Shock  follows  some  one  event.  When 
similar  symptoms  are  produced  by  failing  vitality,  as  dur- 
ing the  course  of  a  serious  illness,  the  term  collapse  is 
used. 

The  actual  way  in  which  shock  is  produced  is  not  clearly 
understood.  It  is  considered  that  the  controlling  influ- 
ence exercised  by  the  nervous  system  on  the  vital  organs 
of  the  body  is  relaxed,  with  the  result  that  the  functional 
activity  of  these  organs  is  impaired  or  temporarily  ar- 
rested. 

The  symptoms  of  shock  are  pallor,  a  rapid,  feeble  pulse, 
frequently  irregular,  shallow  sighing,  irregular  respiration, 
and  subnormal  temperature,  pinched  features,  cold 
extremities,  clammy  skin,  muscular  relaxation,  and,  fre- 
quently, syncope.  Mental  apathy  or  drowsiness  are  com- 
mon, and,  in  severe  cases,  total  loss  of  consciousness. 
On  the  other  hand,  the  senses  may  at  first  be  abnormally 
acute  and  the  mind  alert  and  clear,  almost,  in  fatal  cases, 
to  the  time  of  death.  Nausea  and  vomiting  may  be 
present  and  are  usually  considered  favorable  symptoms, 
showing  a  return  of  vitality  to  the  nerve-centers. 

592 


SHOCK  593 

The  condition  of  shock  or  collapse  is  probably  the  most 
common  emergency  in  nursing,  and  as  the  successful 
treatment  depends  upon  early  recognition  of  the  symptoms, 
the  observation  must  be  trained  to  detect  the  signs 
promptly. 

Treatment  is  directed  toward  restoring  the  vitality  of 
the  nerve-centers  and  to  the  relief  of  the  physical  con- 
dition. 

It  will  be  remembered  that  the  important  nerve-centers, 
such,  for  example,  as  those  controlling  the  action  of  the 
heart  or  governing  the  movements  of  respiration,  are 
contained  in  the  medulla  oblongata,  the  expanded  end  of 
the  spinal  cord  which  is  situated  at  the  base  of  the  brain. 
By  placing  the  patient  in  the  recumbent  position,  with 
the  head  low,  a  further  supply  of  blood  is  directed  to  the 
nerve-centers.  The  pillows  should  be  removed  and  the 
bottom  of  the  bed  elevated.  The  loss  of  heat  to  the 
body  is  conteracted  by  the  application  of  external  heat, 
hot  blankets,  hot-water  cans  or  bags,  and  friction  of  the 
extremities  under  cover.  Fresh  air  is  a  necessity  for  the 
failing  respiration,  though  its  importance  is  sometimes 
overlooked.  If  not  freely  procurable,  oxygen  may  be 
ordered.  To  stimulate  the  circulation  normal  salt  solu- 
tion (500  c.c.  at  a  temperature  of  115°  to  120°  F.)  may  be 
given  by  hypodermoclysis,  by  enteroclysis,  or  by  intraven- 
ous infusion. 

Stimulants  are  usually  given  unless  hemorrhage  is  also 
present,  or  in  cases  of  injury  to  the  head.  Atropin,  the 
most  powerful  respiratory  and  cardiac  stimulant  known, 
strychnin,  ether,  or  camphor,  are  generally  given  by  hypo- 
dermic to  insure  prompt  action.  Whisky,  brandy,  strong 
hot  coffee,  or  tea  may  be  given  by  mouth,  or,  if  the  patient 
is  unconscious,  by  enema.  If  the  abdomen  or  pelvis  is 
injured  or  hemorrhage  is  present,  nothing  should  be  given 
by  mouth  without  special  orders. 

The  electric  battery,  a  mustard  plaster  over  the  heart, 
the  hot  mustard  foot-bath,  are  means  also  employed  for 
the  purpose  of  indirect  stimulation  of  the  nerve-centers. 

After  an  accident  the  symptoms  of  shock  may  be  marked 
by  temporary  excitement  and  develop  after  the  lapse  of 
38 


594       NURSING    IN    ACCIDENTS   AND   EMERGENCIES 

some  hours.  Both  in  slight  and  severe  accidents  the 
probability  of  shock  should  be  borne  in  mind.  This  is 
especially  so  in  cases  of  burns  and  scalds,  and  particularly 
in  children.  The  worst  effects  may  often  be  averted  by 
prompt  preliminary  treatment  of  rest  in  the  recumbent 
position,  quiet,  and  the  application  of  external  heat. 
Close  watch  must  be  kept  on  the  pulse,  a  rapid,  feeble 
pulse  being  usually  the  earliest  indication  of  the  condition 
of  shock. 

The  after-effects  of  severe  shock  are  a  raised  tempera- 
ture due  to  reaction,  lightheadedness,  and  sometimes 
delirium;  the  physical  prostration  may  last  some  time.  In 
alcoholic  patients  delirium  tremens  is  apt  to  develop  and 
is  first  evinced  by  inability  to  sleep. 

The  treatment  is  rest  in  bed,  enforced  quiet,  and  a  light 
nourishing  diet  until  the  normal  condition  is  attained. 
If  there  is  excitement  or  wakefulness,  sedatives  or  narcotics 
are  generally  ordered.  If  a  stimulant  is  given  it  is  usually 
digitalis,  which  is  a  tonic  to  the  heart. 

HEMORRHAGE 

By  hemorrhage  is  understood  an  escape  of  blood  from 
a  blood-vessel.  A  severe  loss  of  blood  to  the  system  may 
prove  rapidly  fatal,  and  is  always  a  serious  drain  on  the 
vitality.  It  is,  therefore,  imperative  that  the  presence 
of  hemorrhage  should  be  immediately  recognized  in  order 
that  it  may  be  promptly  controlled. 

Hemorrhage  may  occur  from  rupture  of  an  artery,  a 
vein,  or  a  capillary. 

Bleeding  from  an  artery  is  bright  red  in  color  and  occurs 
in  jets  or  spurts,  corresponding  to  the  beating  of  the  pulse. 
If  a  large  artery  is  injured,  hemorrhage  may  prove  fatal 
in  a  few  minutes. 

In  bleeding  from  a  vein  the  blood  is  dark  in  color  and 
the  flow  steady,  slow,  and  uninterrupted.  The  reason 
for  the  difference  of  color  is  that  by  the  time  the  blood 
has  reached  the  veins  it  has  parted  with  its  oxygen,  to 
which  it  owes  its  bright  red  color,  and  taken  up  carbonic 
acid  gas,  a  product  of  combustion.  After  venous  blood 
has  been  exposed  to  the  fresh  air  it  again  becomes  oxidized 


HEMORKHAGK  595 

and  bright  red.  The  veins  have  not  the  elastic  resistance 
of  the  arteries,  therefore  the  stream  flows  without  inter- 
ruption. 

Bleeding  from  the  capillaries  occurs  as  a  general  oozing. 
Over  a  large  surface  capillary  bleeding  may  mean  a  con- 
siderable loss,  and  is  often  difficult  to  control. 

Varieties. — Hemorrhage  is  said  to  be  traumatic  when  it 
is  the  result  of  a  wound;  spontaneous,  when  it  occurs  with- 
out previous  injury  to  the  tissues.  Traumatic  hemorrhage 
is  primary  when  it  occurs  at  the  time  the  wound  is  in- 
flicted; secondary,  if  it  occurs  at  a  later  period,  in  some 
instances  hours,  in  others  days,  after  the  time  of  injury. 

The  most  common  causes  of  secondary  hemorrhage 
are  the  slipping  of  a  ligature,  usually  occurring  within 
the  first  twenty-four  hours,  and  the  separation  of  sloughs, 
occurring  after  the  lapse  of  several  days.  It  may  also 
result  from  the  quickening  of  the  circulation  due  to  a 
return  of  vitality  after  conditions  of  severe  shock,  in  small 
unligatured  vessels. 

Hemorrhage  may  be  external,  subcutaneous,  or  internal. 
Internal  hemorrhage  may  be  revealed  or  concealed. 

In  revealed  hemorrhage  the  blood  escapes  by  the  orifice 
nearest  to  the  bleeding  point,  such  as  the  mouth  or  nose, 
the  rectum  or  vagina.  In  concealed  hemorrhage  the  blood 
cannot  escape  and  the  condition  is  entirely  diagnosed  by 
the  physical  symptoms,  the  effect,  that  is,  of  the  loss  of 
blood  on  the  system. 

Physical  Symptoms  of  Hemorrhage. — The  first  and 
most  important  of  these  symptoms  is  a  sudden  change  in 
the  pulse,  which  becomes  rapid,  soft,  and  frequently  irreg- 
ular, at  the  same  time  there  are  usually  pallor  and  faint- 
ness.  If  the  hemorrhage  is  not  quickly  checked,  further 
symptoms  rapidly  develop.  The  most  prominent  are 
shallow  and  irregular  respirations,  accompanied  by  sigh- 
ing, yawning,  and  later  the  condition  of  air-hunger  already 
described,  in  which  the  patient  gasps  and  fights  for  breath; 
cyanosis  or  blueness  of  the  skin  and  mucous  membranes, 
noticeable  first  around  the  lips  and  later  under  the  nails 
of  the  fingers  and  toes;  restlessness,  anxiety,  and  pro- 
found exhaust  ion.  Fainting  or  syncope  is  a  favorable 


596       NURSING    IN   ACCIDENTS   AND    EMERGENCIES 

condition,  the  feeble  action  of  the  heart  causing  the  blood 
to  flow  less  forcibly.  Unless  the  syncope  threatens  to 
become  collapse  no  treatment  is  given  for  the  relief  of 
this  condition  until  the  hemorrhage  is  arrested,  other  than 
placing  the  patient  in  the  recumbent  condition. 

TREATMENT  OF  HEMORRHAGE 

The  primary  treatment  of  all  hemorrhages  is  the  arrest 
of  the  hemorrhage;  second  to  this  (unless  the  patient  is  in 
extremis)  comes  the  treatment  of  the  physical  condition. 

To  a  certain  extent  the  quantity  of  blood  lost  may  be 
controlled  by  position.  In  the  recumbent  position  the 
heart  acts  less  forcibly,  consequently  the  flow  of  blood 
from  the  divided  vessel  is  also  less  forcible.  The  supply 
of  blood  to  a  part  is  also  considerably  lessened  if  the  part 
is  elevated.  The  first  treatment  in  hemorrhage  is  to 
make  the  patient  lie  down  flat  and  elevate  the  injured 
part.  The  head  must  be  kept  low  (as  in  shock),  the  pillows 
removed,  and,  as  a  rule,  the  bottom  of  the  bed  elevated. 

If  the  bleeding  is  from  an  extremity,  the  limb  is  easily 
elevated  by  suspension  or  on  pillows.  The  supply  of 
blood  is  further  lessened  if  at  the  same  time  the  joint 
above  the  bleeding  point  is  acutely  flexed.  In  hemorrhage 
from  the  lower  part  of  the  trunk  the  elevation  of  the  foot 
of  the  bed  will  also  elevate  the  injured  part.  In  hemor- 
rhage from  the  head  or  upper  part  of  the  trunk  it  is  best 
to  keep  the  patient  quite  flat  unless  special  orders  are  given 
to  raise  the  head  of  the  bed,  in  which  case  the  pulse  must 
be  very  closely  watched,  in  case  fatal  syncope  should 
result. 

Hemorrhage  is  arrested  by  closing  the  blood-vessel, 
either  by  the  formation  of  a  clot,  by  causing  contraction 
of  the  walls  of  the  vessel,  or  by  mechanical  means.  The 
methods  used  are  as  follows: 

Exposure  of  the  bleeding  point  to  the  air. 

Pressure,  either  direct  or  indirect. 

The  application  of  heat  or  cold. 

The  direct  application  of  astringents  or  styptics. 

The  indirect  action  of  styptics  administered  by  mouth 
or  hypodermically. 


HEMORRHAGE 


597 


Subclavian 


Axillary 


Brachial 


Palmar  arch 

Femoral 
Popliteal 

Anterior  tibial 
Posterior  tibial 


Temporal 

Facial 

External  carotid 
Common  carotid 


Fig.  178. — The  relation  of  the  principal  arteries  to  the  bones  and 
joints.  The  arrows  indicate  the  points  where  pressure  may  best  be 
applied  (Morrow). 


598 

Mechanical  closing  of  the  ruptured  vessel  either  by 
ligation  or  by  torsion. 

Exposure  to  the  Air. — Blood  on  exposure  to 'the  air 
naturally  clots.  In  mild  cases  exposure  of  the  bleeding 
point  to  the  air  may  be  sufficient  to  arrest  the  hemor- 
rhage, the  part  at  the  same  time  being  elevated  and  the 
patient  in  the  recumbent  position.  When  the  bleeding  is 
controlled,  a  sterile  dressing  should  be  firmly  applied. 

Pressure. — Direct  pressure  is  usually  applied  by  means 
of  pads  or  packing  of  sterile  gauze. 

Whatever  the  haste,  it  must  not  be  forgotten  that  the 
bleeding  surface  may  easily  be  infected,  and  should  come 
in  contact  with  nothing  that  is  not  surgically  clean. 


Fig.  179. — Digital  compression  of  brachial  artery  (Marwedel). 


If  the  wound  is  deep,  it  is  lightly  packed  with  narrow 
strips  of  sterile  gauze  or  a  narrow  bandage,  over  which  a 
pad  is  applied  with  a  firm  bandage.  Where  the  wound  is 
in  a  hollow,  such  as  the  palm  of  the  hand,  the  axilla,  etc., 
several  pads  are  applied,  the  first  small  enough  to  fit  the 
wound,  and  each  succeeding  layer  a  littler  larger,  forming 
a  graduated  compress. 

In  hemorrhage  from  an  orifice,  such  as  the  vagina, 
pressure  may  be  applied  to  the  bleeding  point  by  packing 
the  entire  cavity  tightly  with  gauze.  (See  Chap.  VI.) 
Pads  or  packing  applied  for  the  purpose  of  arresting  hemor- 
rhage must  be  closely  and  repeatedly  examined  to  ascer- 
tain whether  blood  is  not  soaking  through  the  dressing. 


HEMORRHAGE 


599 


At  the  same  time  it  should  be  remembered  that  where 
a  wound  is  hidden  by  thick  dressings,  a  revealed  hemor- 
rhage may  be  thus  converted  into  a  concealed  hemor- 
rhage, of  which  the  only  evidences  are  the  physical  symp- 
toms of  hemorrhage.  The  pulse,  therefore,  and  the  color 
of  the  patient  must  be  closely  watched,  in  order  that  the 


Fig.  180. — Forced  flexion  of  the  elbow  (Morrow). 


first  symptoms  of  a  recurrence  may  be  promptly  noticed. 
In  removing  dressings  for  pressure,  it  will  be  found  that 
the  blood  has  caused  them  to  adhere  closely  to  the  in- 
jured site.  To  pull  on  the  dressing  may  reopen  the 
bleeding  point.  They  should  be  soaked  with  cold1  sterile 
water  until  they  come  away  without  force.  The  dressing 

1  Warm  water,  by  relaxing  the  parts,  may  again  start  the  bleeding. 


600       NURSING    IN    ACCIDENTS   AND    EMERGENCIES 

is  removed  usually  after  twenty-four  hours.  In  some 
cases  the  outer  dressing  only  is  removed  and  that  next  the 
wound  left  for  another  twenty-four  hours. 

Direct  pressure  is  used  in  mild  hemorrhages  and  in  cases 
where  the  bleeding  vessel  is  not  sufficiently  exposed  to  be 
easily  ligated.  (Hemorrhage  from  the  Nares,  see  below.) 


Fig.  181. — Compression  of  the  radial  and  ulnar  arteries  at  the  wrist 
(Morrow) . 


Indirect  pressure  is  used  as  a  temporary  means  of  arrest- 
ing external  hemorrhage,  especially  in  injuries  to  an  ex- 
tremity. The  pressure  is  applied  at  a  point  along  the 
course  of  the  main  vessel,  supplying  the  part,  and  either 
above  or  below  the  bleeding  spot,  according  to  whether 
the  injury  is  to  an  artery  or  to  a  vein.  Injury  to  a  main 
artery  is  a  very  serious  condition,  cutting  off  the  main 


HEMORRHAGE  601 

supply  of  blood  to  the  part,  and  may  be  followed  by  gan- 
grene.    Owing  to  their  protected  position  deep  in  the 


Fig.  182. — Compression  of  the  subclavian  artery  (Morrow). 


Fig.  183. — Forced  flexion  of  the  knee  (Morrow). 

tissues,  the  main  arteries  are  less  frequently  injured  than 
the  smaller  and  more  superficial  vessels.     The  blood  in 


602       NURSING   IN   ACCIDENTS  AND   EMERGENCIES 

an  artery  flows  from  the  heart  toward  the  extremities; 
indirect  pressure  is,  therefore,  applied  between  the  bleed- 


Fig   184. — Digital  compression  of  femoral  artery  (Marwedel). 


Fig.  185. — Compression  of  the  temporal  artery  (Morrow). 


ing  point  and  the  heart;  in  a  vein  the  blood  is  flowing  to- 
ward the  heart,  and  indirect  pressure  is,  therefore,  applied 


HEMORRHAGE  603 

below  the  bleeding  point,  that  is,  with  the  bleeding  point 
between  the  heart  and  the  point  of  pressure. 

The  methods  commonly  used  to  apply  indirect  pressure 
are  digital  pressure  and  the  application  of  a  tourniquet. 

In  digital  pressure  the  main  blood-vessel  is  compressed 
between  the  fingers  and  the  bone,  over  the  outer  surface  of 
which  the  vessel  passes.  In  order  to  apply  digital  pressure 
the  course  of  the  principal  blood-vessels  must  be  known, 
and  the  points  at  which  they  can  best  be  reached  (the 
digital  point).  This  should  be  taught  by  the  use  of  ana- 


Fig.  186. — Compression  of  the  facial  artery  (Morrow). 

tomic  charts  and  by  demonstrations  in  class.  When 
pressure  sufficient  to  control  a  hemorrhage  is  made  on 
an  artery,  the  pulse  below  the  point  of  pressure  is  ob- 
literated. 

It  is  difficult,  without  experience,  to  make  digital  press- 
ure sufficiently  firm  to  control  hemorrhage.  The  appli- 
cation of  a  tourniquet,  where  practical,  is,  therefore, 
commonly  the  more  reliable  method. 

The  principal  digital  points  for  the  different  arteries 
are  as  follows: 


604       NURSING   IN   ACCIDENTS  AND   EMERGENCIES 


The  forearm  Brachial  artery.  Inner  surface  of  the  arm  (upper), 
or  hand.  between  the  two  large  muscles, 

against  the  humerus,  at  a  point 
about  one-third  the  distance  from 
the  axilla  to  the  elbow.  The  elbow 
should,  at  the  same  time,  be  forci- 
bly flexed  and  a  pad  inserted  in 
the  bend. 

The  hand.  Ulna  and  radial  Preferably,  as  above,  also  at  the 
arteries.  wrist.  Against  the  radius,  on  the 

inner  surface,  at  the  thumb  side, 
and  against  the  ulna  on  the  inner 
surface  on  the  side  of  the  little 
finger;  the  elbow  is  flexed  and  the 
hand  elevated. 

The  axilla  or  Subclavian  Against  the  clavicle  from  behind, 
shoulder.  artery.  about  midway  between  the  point 

of  the  shoulder  and  the  sternum. 

The  leg  and  Popliteal  artery.  Behind  the  knee,  against  the  femur. 
foot.  Best  applied  by  placing  a  pad 

behind  the  knee  (the  popliteal 
space)  and  acutely  flexing  the 
knee.  'The  thigh  must  also  be 
flexed  in  order  to  keep  the  part 
elevated. 

The  thigh.  Femoral  artery.  Against  the  rim  of  the  pelvis  in  the 

groin,  at  the  point  where  the 
femoral  pulse  is  felt,  i.  e.,  about 
two-thirds  the  distance  from  the 
hip  to  the  middle  line  of  the  body. 
The  whole  extremity  should  be 
elevated,  the  thigh  slightly  flexed. 

The  scalp.  Temporal  Against  the  zygoma  where  the  pulse 
artery.  can  be  felt,  directly  in  front  of  the 

ear,  opposite  the  external  opening 
of  the  auditory  canal. 

The  face.  Facial  artery.  Against  the  lower  jaw  bone,  where 

the  pulse  can  be  felt,  at  a  point 
below  the  angle  of  the  mouth,  at 
the  anterior  edge  of  the  masseter. 

A  tourniquet  is  made  of  a  piece  of  thick,  strong  elastic 
rubber,  flat  or  round,  sufficiently  long  to  pass  two  or  three 
times  round  a  limb,  and  provided  with  some  mechanism 
by  which  it  can  be  securely  clamped  and  held  without 
slipping.  Fastened  tightly  round  a  limb,  it  will  effectually 
stop  the  circulation  and,  therefore,  arrest  hemorrhage. 
It  should  not  be  left  on  more  than  an  hour,  or  gangrene 
of  the  part  may  result.  In  applying  the  tourniquet,  the 


HEMORRHAGE  605 

part  should  first  be  protected  by  a  piece  of  lint,  or  several 
folds  of  gauze,  etc.,  in  order  to  prevent  pinching  and 
bruising  of  the  skin.  If  it  can  be  applied  at  the  digital 
point,  a  small  hard  pad  should  be  inserted  under  the  tour- 
niquet, over  the  exact  point  of  digital  pressure.  A  roller 
bandage  makes  a  serviceable  pad. 


Fig.  187. — The  field  tourniquet  (Morrow). 

A  tourniquet  may  be  improvised  with  a  handkerchief 
or  a  piece  of  bandage.  It  should  be  passed  twice  round 
the  limb,  and  knotted  with  a  double  knot  over  the  digital 
point,  a  hard  pad  being  inserted  under  the  bandage  below 
the  knot.  Through  the  knot  a  piece  of  wood  or  a  pair 
of  scissors,  etc.,  is  slipped  and  twisted  tightly  round  and 


Fig.  188. — The  application  of  the  field  tourniquet  (Morrow). 

round,  thus  tightening  the  tourniquet  and  pressing  the 
pad  against  the  artery. 

In  applying  indirect  pressure  to  a  vein  the  bleeding 
point  itself  must  first  be  covered  by  a  sterile  pad,  in  order 
to  exclude  air  from  the  empty  vessel.  In  the  case  of  injury 


606        NURSING   IN   ACCIDENTS   AND    EMERGENCIES 

to  a  large  vein,  for  the  same  reason,  pressure  is  applied 
above  as  well  as  below  the  lesion.  As  a  rule,  venous  hem- 
orrhage is  best  controlled  by  direct  pressure  at  the  bleeding 
point. 


Fig.  189. — Improvised  tourniquet  (Stoney). 

Acupressure. — An  old-fashioned  means  of  applying 
indirect  pressure  is  known  as  acupressure.  A  needle  is 
passed  through  the  tissue  on  either  side  of  the  course  of 


Fig.  190. — Showing  so-called  Spanish  windlass,  an  improvised  tour- 
niquet, compressing  the  brachial  artery  (de  Nancrede) . 


an  artery.  A  piece  of  silk  is  then  wound  tightly  round  the 
needle,  in  a  figure-of-8,  thus  causing  compression  of  the 
artery.  The  needle  is  removed  in  from  six  to  eight  hours. 


HEMORRHAGE 


607 


At  the  present  day  acupressure  is  rarely  used.  It  is 
considered  chiefly  of  value  for  such  parts  where  a  tourni- 
quet is  impractical,  as  in  hemorrhage  from  the  scalp  or 
in  the  treatment  of  ruptured  varicose  veins. 

Indirect  pressure  is  never  more  than  a  temporary 
treatment.  For  the  actual  arrest  of  hemorrhage  it  is 
necessary  that  the  ruptured  vessel  should  be  sealed,  either 
by  the  formation  of  a  clot,  by  inducing  the  walls  of  the 
vessel  to  contract,  or  by  mechanically  closing  the  vessel. 

Heat  and  Cold. — Heat  may  be  applied  to  a  bleeding 
point  in  the  form  of  a  douche  or  irrigation  of  very  hot 
sterile  water  (114°  to  120°  F.),  or  by  the  application  of 
the  actual  cautery.  The  application  of  heat  both  induces 


Fig.  191.— Method  of  employing  acupressure  by  means  of  a 
threaded  needle  passed  behind  and  a  figure-of-8  wire  passed  in  front 
of  vessel  (de  Nancrede). 

the  contraction  of  the  arterial  walls,  and  causes  the  blood 
to  clot  by  coagulating  the  albumin;  it  is,  therefore,  a 
valuable  agent.  Hot  irrigation  of  sterile  water  is  a  com- 
mon means  of  arresting  hemorrhage  from  vessels  in  exten- 
sive operations  or  in  troublesome  capillary  oozing.  The 
water  used  must,  however,  be  not  less  than  the  above 
temperature.  Water  merely  warm  encourages  hemor- 
rhage by  causing  relaxation  of  the  arteries.  Care  must  be 
taken  to  prevent  the  skin  from  being  scalded,  the  mucous 
membranes  and  the  internal  tissues  bearing  readily  a 
moist  heat  that  will  injure  the  skin. 

The  actual  cautery  (see  Chap.  Ill)  is  frequently  used 
at  operations  to  control  a  general  oozing  over  a  more  or 


608        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 

less  extensive  surface.  Its  chief  use  is  in  rectal  operations. 
If  not  used  with  caution,  it  may  cause  extensive  sloughing. 

Cold  arrests  hemorrhage  by  causing  contraction  of  the 
vessels.  It  is  applied  in  the  form  of  ice,  ice  suppositories, 
ice  compresses  and  ice-bags,  or  irrigations  of  ice  water. 

Cold  water  dissolves  albumin,  and  thus  delays  the  coag- 
ulation of  the  blood,  though  it  favors  contraction  and 
constriction  of  the  arteries.  It  is,  on  the  whole,  a  less 
valuable  agent  for  the  purpose  than  hot  water.  It  can, 
however,  be  used  in  many  cases  where  the  application 
of  hot  water  of  the  necessary  temperature  is  not  practical, 
as,  for  example,  in  hemorrhage  from  a  throat,  where  there 
is  risk  of  scalding  of  the  adjacent  tissues,  which  would  be 
a  dangerous  complication. 

Astringents  and  Styptics. — An  astringent  is  a  drug 
that  produces  contraction  of  the  tissues  and  reduces 
secretions;  many  of  them,  such  as  the  acid  astringents, 
also  coagulate  the  albumin  of  the  blood,  thus  forming 
a  clot.  Properly  speaking,  heat  and  cold  are  also  astrin- 
gents. The  most  commonly  used  astringent  in  treating 
hemorrhage  is  acetic  acid,  or  vinegar.  It  is  generally 
given  in  conjunction  with  the  hot  douche — acetic  acid, 
Y  ounce,  to  water,  1  pint  (vinegar,  I  ounce  to  1  pint). 
Powerful  astringents  are  called  styptics,  or,  from  the  fact 
that  they  check  hemorrhage,  hemostatics.  The  most 
commonly  used  are:  Adrenalin  chlorid  (solution,  1  :  10,000 
to  1  :  25,000) ;  tannic  acid  (powder,  or  saturated  solution  in 
glycerin);  alum  (saturated  solution);  iron  (either  tinctura 
ferri  chloridi,  or  Monsell's  solution);  nitrate  of  silver 
(solution,  4  to  10  per  cent.,  or  stick).  They  are  applied 
directly  to  the  bleeding  point,  either  by  an  applicator  or 
in  the  form  of  a  spray  (nose  and  throat). 

The  metal  astringents,  while  effectually  checking  hemor- 
rhage, cause  later  sloughing  of  the  tissues,  with  the  risk 
of  further  hemorrhage;  their  use,  therefore,  is  limited. 
When  available,  either  adrenalin  or  tannic  acid  is  preferred. 
Preparations  containing  tannic  acid,  such  as  witch- 
hazel,  are  excellent  as  domestic  remedies.  Styptic  collodion, 
a  preparation  of  collodion  and  tannic  acid  (20  per  cent.), 
and  styptic  cotton,  an  absorbent  cotton  charged  with  iron 


HEMORRHAGE  609 

sulphate,  are  occasionally  used  in  the  dressing  of  wounds 
complicated  by  troublesome  hemorrhage. 

A  hemorrhage  may  also  be  controlled  indirectly  by  the 
administration  of  hemostatics  internally,  either  by  hypo- 
dermic injection  or  by  the  mouth  or  rectum.  Taken 
into  the  system,  their  action  is  to  cause  constriction  of  the 
smaller  blood-vessels.  Those  most  frequently  used  are: 
Adrenalin  chlorid  (mouth,  10  to  30  minims;  hypodermic- 
ally,  diluted  ten  times  with  normal  salt  solution),  ergot 
(mouth,  fluidextract,  30  minims  to  1  dram :  hypodermically, 
ergotin,  2  to  5  grains),  and  gallic  acid  (pill  form,  10  to  30 
grains).  Ergot,  besides  causing  constriction  of  the  blood- 
vessels, acts  directly  on  the  muscular  tissue  of  the  uterus, 
causing  powerful  contractions;  it  is,  therefore,  of  great 
service  in  the  treatment  of  postpartum  hemorrhage. 

In  conditions  that  favor  hemorrhages,  such  as  the  exist- 
ence of  sloughing  ulcers  (as  in  typhoid  fever),  in  the  treat- 
ment of  aneurysm,  and  of  those  diseases  complicated  by 
spontaneous  hemorrhages  (see  below),  substances  that 
favor  the  clotting  of  blood  are  frequently  administered 
regularly  over  a  length  of  time.  The  principal  are  calcium 
chlorid  (10  grains)  and  gelatin.  The  latter  is  generally 
given  in  the  diet  in  the  form  of  jellies,  but  may  also  be 
administered  by  rectum.  In  the  latter  case  it  must  be 
diluted  until  sufficiently  thin  to  flow  through  the  enema 
tube.  More  rarely  it  is  given  by  hypodermic  injection, 
diluted  to  a  2  per  cent,  solution  in  sterile  water. 

Ligature. — The  mechanical  method  of  arresting  hemor- 
rhage is  by  ligating  the  bleeding  vessel.  The  vessel  is 
seized  by  a  pair  of  forceps,  slightly  stretched,  and  the 
ligature  tied  round  it  in  a  firm  surgical  knot.  Unless 
securely  tied  (p.  328),  the  ligature  may  slip,  causing  a 
secondary  hemorrhage.  Ligatures  are  usually  of  catgut, 
which  can  be  absorbed  into  the  tissues.  Ligation  of  the 
vessels  is  the  usual  method  of  arresting  hemorrhage 
caused  by  an  operation. 

Torsion,  or  twisting  of  an  artery,  is  a  means  of  contrac- 
tion chiefly  used  for  the  smaller  vessels.  If  an  artery  is 
cut  clean  across,  the  walls  do  not  contract.  If,  however, 
the  walls  are  torn  or  divided  unequally,  the  elastic  fibers 


610        NURSING    IN   ACCIDENTS   AND    EMERGENCIES 


in  the  walls  of  the  artery  tend  to  curl  up  on  themselves, 
thus  contracting  and  closing  the  vessel,  and  forming,  at 
the  same  time,  an  irregular  surface  on  which  fibrin  is  readily 
deposited.  In  torsion  the  artery  is  seized  in  a  pair  of 
forceps,  stretched,  and  twisted.  The  walls  are  broken  and 
contraction  induced. 

Treatment  of  the  Physical  Condition. — Ordinarily, 
until  the  hemorrhage  is  arrested,  the  treatment  of  the 
physical  condition  is  confined  to  placing  the  patient  in  the 
recumbent  position,  usually  with  the  head  low  and  the 
feet  elevated,  for  the  reasons  given  above,  at  the  same  time 
preventing  any  movement  that  may  exhaust  him  and 
cause  further  loss  of  blood;  always  remember  he  should 
have  plenty  of  fresh  air.  No  stimulants  should  be  given: 


Fig.  192. — Method  of  controlling  hemorrhage  by  torsion  (Da  Costa). 

they  tend  to  increase  hemorrhage.  If  a  drink  cannot  be 
denied,  it  should  be  cold  water.  Faintness  need  not  be 
relieved  unless  it  tends  to  pass  into  fatal  syncope.  Ex-' 
ternal  warmth,  by  restoring  the  vitality,  also  favors  hemor- 
rhage. The  general  condition  of  the  patient  and  the 
promptness  with  which  surgical  help  can  be  obtained 
must  frequently  determine  how  far  the  physical  condition 
can  be  relieved  .before  the  hemorrhage  is  checked. 

When  the  hemorrhage  is  arrested,  treatment  is  directed 
toward  restoring  the  vitality.  The  condition  is  one  of 
extreme  shock,  and  the  treatment  is  on  the  same  lines. 
The  patient  is  kept  in  the  recumbent  position,  with  the 
feet  well  elevated.  After  severe  hemorrhage,  or  if  there 
is  danger  of  recurrence,  the  position  is  maintained  until 
a  normal  condition  is  reestablished,  when  the  bed  should 


HEMORRHAGE  611 

be  lowered  gradually — not  more  than  half  a  foot  a  day. 
External  heat  is  applied  in  the  form  of  hot  blankets,  hot- 
water  cans,  and  friction  of  the  extremities  under  cover. 
Large  poultices  are  sometimes  ordered  to  the  calves  of 
the  legs  and  over  the  abdomen;  in  the  collapsed  condition 
of  the  patient  they  are,  however,  likely  to  cause  burns, 
unless  closely  watched  and  removed  on  the  first  sign  of 
reddening.  Hypodermoclysis  or  intravenous  infusions 
of  normal  salt  solution  (500  c.c.),  or  enemata  of  hot  normal 
salt  solution  (200  to  500  c.c.),  are  generally  given  for  the 
purpose  of  restoring  fluid  to  the  circulation. 

Intense  thirst  is  a  prominent  after-effect  of  hemorrhage. 
Where  practical,  water,  tea,  etc.,  are  given  freely  by  mouth; 
in  other  conditions  the  thirst  is  best  combated  by  sips  of 
boiling  hot  water.  Stimulants  may  be  ordered,  but  are 
given  with  caution  on  account  of  the  risk  of  a  recurrence 
of  the  hemorrhage.  For  the  immediate  results,  atropin, 
strychnin,  or  alcohol  is  generally  ordered;  in  the  after- 
treatment  digitalis  is  preferred,  as  it  acts  as  a  tonic  to  the 
heart.  Morphin  (yV  to  T  grain)  is  frequently  ordered, 
especially  in  hemorrhages  connected  with  the  alimentary 
tract.  It  reduces  the  general  restlessness  and,  by  check- 
ing peristalsis,  restrains  local  movement. 

Where  the  loss  of  blood  has  been  severe,  auto-infusion 
may  be  practised  in  order  to  keep  as  much  blood  as  pos- 
sible circulating  in  the  vital  organs.  The  extremities 
.are  elevated  and  firmly  bandaged  from  the  tips  of  the 
fingers  or  toes  toward  the  trunk.  Usually  one  of  the  four 
limbs  is  left  unbandaged,  and  every  ten  minutes  the  band- 
ages from  one  limb  are  changed  to  the  unbandaged  limb. 
In  this  way  no  limb  is  bandaged  for  longer  than  half  an 
hour  at  a  time. 

The  immediate  after-effects  of  hemorrhage  are  exhaus- 
tion, intense  thirst,  and  anemia.  The  pulse  is  slow — 
in  severe  cases  frequently  lower  than  45.  Later  there 
may  be  fever,  with  lightheadedness  or  delirium.  The 
treatment  is  the  same  described  for  delayed  shock.  Hy- 
podermoclysis of  normal  salt  solution  is  frequently  ordered 
at  repeated  intervals.  Hot  water  and  hot  drinks,  such  as 
tea,  relieve  the  thirst  more  efficiently  than  cold  drinks  or 


612        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 

ice.  The  anemia  is  treated  with  prolonged  rest,  fresh  air, 
a  nourishing  diet,  and  usually  iron  in  some  form  is  ordered 
(Blaud's  pills,  or  tinctura  ferri  chloridi,  etc.).  It  is  often  a 
very  persistent  symptom,  and  is  an  undesirable  complica- 
tion, especially  after  an  operation,  prolonging  convales- 
cence and  delaying  recovery. 

SPECIAL   FORMS    OF   HEMORRHAGE 

External  hemorrhage  is  hemorrhage  occurring  on  the 
surface  of  the  body,  and  is  almost  invariably  the  result 
of  violence.  It  is  the  most  simple  form  of  hemorrhage  to 
treat,  being  quickly  recognized,  and  the  local  treatment 
generally  easy  to  apply.  Care  must  be  exercised  to  keep 
the  wound  sterile.  Arterial  external  bleeding  may  be 
controlled  by  any  of  the  methods  described  above. 

If  the  hemorrhage  is  venous,  the  best  method  of  con- 
trolling it  is  usually  direct  local  pressure  with  a  graduated 
pad,  the  part  being  well  elevated.  The  commonest  form 
of  venous  bleeding  is  a  ruptured  varicose  vein  in  the  leg. 
After  the  pad  is  applied,  the  whole  limb  is  enveloped  in  a 
rubber  bandage,  beginning  at  the  toes  and  bandaging 
upward.  In  obstinate  cases,  where  bleeding  tends  to 
recur,  an  operation  may  be  necessary,  and  the  vein  is 
ligated.  For  these  cases  also  acupressure  is  still  occa- 
sionally performed.  In  external  capillary  bleeding  ex- 
posure to  the  air  may  be  sufficient  to  check  the  oozing. 
If  not,  direct  pressure  or  the  application  of  heat,  cold,  or 
an  astringent  is  next  tried.  A  powerful  styptic,  such  as 
iron,  will  always  stop  hemorrhage,  but  where  the  physical 
symptoms  are  not  urgent,  other  methods  should  be  tried 
first,  on  account  of  the  tendency  of  strong  styptics  to 
cause  sloughing. 

Subcutaneous  hemorrhage  is  an  extravasation  of  blood 
into  the  tissues.  It  may  be  the  result  of  injury  (traumatic) 
or  disease  (spontaneous).  The  appearance  of  traumatic 
subcutaneous  hemorrhage  is  familiarly  recognized  as 
bruising.  The  bleeding  is  diffused  over  a  more  or  less 
extensive  area,  producing  a  discoloration  of  the  tissue,  at 
first  purple,  then  fading  as  absorption  takes  place  into 


HEMORRHAGE  013 

green  and  yellow.  Such  an  extravasation  of  blood  is 
called  ecchymosis. 

The  treatment  consists  in  the  application  of  cold, 
usually  in  the  form  of  a  compress,  unless  the  injury  is 
extensive,  when  the  lessening  of  the  blood-supply  to  the 
part  increases  the  danger  of  sloughing.  Hot  applications, 
which  dilate  the  vessels,  thereby  increasing  the  blood- 
supply  and  restoring  the  vitality  of  the  part,  are  then 
preferred.  The  cold  application  may  with  advantage  be 
combined  with  an  astringent,  such  as  arnica  or  witch- 
hazel,  which  aids  in  checking  exudation.  They  are  best 
applied  in  the  form  of  compresses. 

Some  diseases  are  characterized  by  minute  extravasa- 
tions of  blood  under  the  skin,  giving  the  appearance  of  a 
rash  of  small  purplish  spots  known  as  petechice.  A  pete- 
chial  hemorrhagic  rash  is  common  in  purpura,  scurvy, 
and  typhus  fever.  It  is  also  met  with  in  malignant  forms 
of  smallpox  and  measles,  and  may  also  less  frequently 
be  met  in  other  conditions.  Small  localized  subcutaneous 
hemorrhages  are  common  in  arteriosclerosis,  a  condition 
in  which  the  arteries  become  hard  and  inelastic  and  are 
easily  ruptured.  Extravasation  of  blood  under  the  con- 
junctiva has  a  bright-red  appearance,  owing  to  the  con- 
stant exposure  of  the  clot  to  oxygen  through  the  thin 
membrane  of  the  conjunctiva,  and  often  causes  unneces- 
sary alarm.  For  these  small  extravasations  no  treatment 
is  necessary.  They  gradually  become  absorbed  and  disap- 
pear. For  these  conditions  no  local  treatment  is  neces- 
sary. 

Internal  hemorrhage  is  always  a  grave  condition.  It 
may  be  serious  from  the  amount  of  blood  lost,  or,  where  the 
blood  cannot  escape,  from  the  effects  of  the  hemorrhage 
on  the  adjacent  structures.  For  example,  a  small  hemor- 
rhage in  the  brain  may,  from  the  pressure  caused  by  the 
clot,  give  rise  to  a  fatal  apoplexy ;  a  slight  hemorrhage  into 
the  lung  may  cause  septic  pneumonia;  bleeding  into  the 
peritoneal  cavity,  though  not  extensive,  will  shortly  set 
up  septic  peritonitis  from  decomposition  of  the  blood. 

As  has  been  said  above,  internal  hemorrhage  may  be 
revealed  or  concealed.  In  revealed  hemorrhage  we  have 


614        NURSING   IN   ACCIDENTS   AND   EMERGENCIES 

the  evidence  of  an  escape  of  blood,  either  from  the  orifice 
of  the  body  nearest  to  the  injured  structure  or  from  a 
wound.  The  bleeding  point  may  frequently  be  reached 
and  local  treatment  applied. 

In  concealed  hemorrhage  the  condition  is  only  demon- 
strated by  the  physical  symptoms  already  described.  It 
is,  therefore,  the  graver  condition,  being  more  liable  to 
be  overlooked. 

The  common  causes  of  internal  hemorrhage  are  as 
follows:  After  an  internal  operation,  from  imperfect 
closing  of  a  vessel,  the  slipping  of  a  ligature,  or  the  separa- 
tion of  sloughs:  from  an  accident  causing  injury  to  an 
internal  organ;  for  example,  fracture  of  the  pelvis  or 
the  skull;  sloughing  of  an  ulcer  causing  perforation  of  a 
blood-vessel  at  some  point  in  the  alimentary  tract:  rup- 
ture of  the  tube  in  a  case  of  Fallopian  gestation:  separa- 
tion of  a  portion  of  the  placenta  previous  to  labor;  relaxa- 
tion of  the  uterus  after  labor:  injury  or  disease  of  one  of 
the  kidneys:  spontaneous  hemorrhage,  usually  from  the 
mucous  membrane  of  some  portion  of  the  alimentary  tract. 

The  symptoms  accompanying  internal  hemorrhage 
are  greatly  modified  by  the  function  and  position  of  the 
organ  affected.  The  characteristic  symptoms  and  the 
special  treatment  necessary  must,  therefore,  be  considered 
in  detail. 

Hemorrhage  from  the  Bowels  (Enterorrhagia). — The 
common  cause  of  enterorrhagia  is  rupture  of  a  vessel  from 
the  perforation  of  an  ulcer,  usually  due  to  separation  of  a 
slough,  in  the  walls  of  the  intestine,  as  in  typhoid  fever. 
It  is  sometimes  directly  caused  by  acute  distention  of  the 
walls  of  the  intestines  before  the  ulcers  have  healed; 
enterorrhagia  may  also  occur  spontaneously  in  purpura 
or  scurvy.  It  is  always  a  grave  condition,  and  frequently 
fatal  to  life,  especially  when  the  patient's  strength  is  re- 
duced by  prolonged  illness,  as  in  typhoid  fever. 

A  discharge  of  blood  and  mucus  from  the  rectum  is  a 
common  symptom  in  inflammatory  conditions  of  the 
alimentary  tract,  as  in  enterocolitis,  or  in  poisoning  by 
corrosives  or  irritants.  It  is  not  dangerous  to  life  in  the 
same  sense.  Hemorrhage  from  internal  hemorrhoids  oc- 


HEMORRHAGE  015 

curs  usually  at  the  time  of  defecation,  and  is  bright  red 
and  passed  on  the  top  of  a  stool. 

The  symptoms  of  enterorrhagia  are  those  of  internal 
hemorrhage  in  a  marked  degree,  as  already  described;  usu- 
ally there  is  a  sudden  fall  in  temperature  and  a  sharp  rise 
in  the  pulse-rate;  distention  is  frequently  present;  sooner 
or  later  there  is  a  discharge  of  blood  from  the  rectum.  If 
the  bleeding  point  is  low,  the  blood  may  be  bright  red  in 
color  and  either  gush  from  the  anus  or  be  passed  in  clots. 
If  the  point  is  high  in  the  bowel,  the  blood  is  "  altered  " 
by  the  digestive  juices,  and  appears  as  a  dark-brown  or 
black,  viscid  fluid,  mixed  with  fecal  matter.  Some  hours 
after  the  hemorrhage  has  occurred  the  stools  are  black  in 
color  and  sticky;  they  are  known  as  tarry  stools  (p.  267). 

The  treatment  consists  in  absolute  rest  on  the  back, 
with  the  bottom  of  the  bed  elevated  higher  than  the 
shoulders,  and  the  pillows  removed.  An  ice-bag  or  Leiter's 
coils  are  applied  to  the  abdomen,  especially  to  the  right 
side,  which  is  the  site  of  the  glands  usually  first  attacked 
in  typhoid  fever.  All  other  treatment  is  stopped.  No 
nourishment  or  water  by  mouth  is  allowed  for  at  least 
twenty-four  hours.  No  movement  of  the  pelvis  must  be 
permitted;  the  stools  are  received  on  pads  of  tow.  The 
skin  of  the  coccyx  may  be  protected  by  a  ring  air-cushion 
slightly  inflated.  The  room  is  kept  at  a  low  temperature 
(55°  to  60°  F.);  the  bed-clothes  should  be  light  and  pre- 
vented by  a  bed-cradle  from  weighing  on  the  abdomen. 

No  stimulants  are  given.  If  exhaustion  is  severe,  hypo- 
dermoclysis  of  normal  salt  solution  is  usually  given. 
Morphin  is  generally  ordered  (yV  to  \  grain),  and  the 
patient  kept  under  the  influence  of  the  drug  until  the  dan- 
ger is  past.  Hemostatics,  such  as  ergot,  may  be  ordered 
and  are  generally  given  by  hypodermic.  If  the  hemorrhage 
tends  to  recur,  a  course  of  calcium  chlorid  (10  grains)  or 
gelatin  is  frequently  ordered  by  mouth  or  rectum.  Close 
watch  must  be  kept  for  symptoms  of  perforation  (p.  624) . 
Treatment  by  mouth  is  renewed  with  caution,  generally 
beginning  with  sips  of  hot  water  after  twenty-four  hours 
to  two  days  have  elapsed.  Three  days  from  an  attack 
the  patient  is  usually  allowed  to  be  turned,  using  no  effort 


GIG        NURSING   IN   ACCIDENTS  AND   EMERGENCIES 

himself,  after  which  the  bed  is  gradually  lowered  and 
normal  conditions  cautiously  resumed. 

Hemorrhage  from  the  bowel  arising  from  hemorrhoids 
is  not  so  serious  a  condition;  the  loss  is  usually  not 
sufficient  to  cause  acute  physical  symptoms.  Rest  for 
a  short  time  in  bed,  the  introduction  of  ice  suppositories  or 
of  a  suppository  containing  an  astringent,  usually  gall  or 
tannic  acid,  is  generally  all  the  treatment  required.  If 
there  is  severe  pain,  opium  or  cocain  is  frequently  combined 
with  the  astringent.  The  feces  are  kept  soft  by  mild 
laxatives. 

Hemorrhage  Due  to  Purpura,  etc. — (See  Spontaneous 
Hemorrhage.) 

Hemorrhage  from  the  Stomach  (Hematemesis). — The 
usual  cause  of  hematemesis  is  perforating  gastric  ulcer; 
it  also  occurs  spontaneously  in  purpura  or  scurvy. 

The  first  symptom  is  frequently  the  vomiting  of  darkish 
blood  mixed  with  mucus  and  food-particles.  (See  Chap. 
VII.)  If  the  bleeding  is  slight  and  the  blood  has  remained 
any  length  of  time  in  the  stomach,  it  is  altered  by  the 
digestive  juices  and  has  the  appearance  of  coffee-grounds. 
Later,  the  stools  are  tarry  from  the  presence  of  blood 
which  has  passed  into  the  intestines.  The  physical  symp- 
toms are  mild  or  grave  according  to  the  loss  of  blood  and 
the  frequency  with  which  the  hemorrhages  recur. 

The  treatment  is  the  same  as  in  hemorrhage  from  the 
bowels.  When  treatment  by  mouth  can  be  resumed, 
gelatin  is  frequently  ordered  as  part  of  the  diet.  In  severe 
cases,  where  attacks  of  hemorrhage  recur,  an  operation  is 
frequently  performed  by  which  the  ulcer  is  excised  and 
the  wall  of  the  stomach  repaired. 

Hemorrhage  from  the  Lungs  (Hemoptysis). — Hemop- 
tysis may  result  from:  (1)  The  breaking-down  of  a  cavity 
involving  the  wall  of  a  blood-vessel  in  pulmonary  tuber- 
culosis; (2)  the  rupture  of  an  aneurysm;  (3)  the  result  of 
venous  congestion  in  heart  disease;  (4)  injury,  as  in  per- 
foration of  the  lung  by  a  fractured  rib  or  a  gunshot  wound. 

In  the  first  condition  the  first  sign  is  usually,  but  not 
invariably,  a  preliminary  cough,  followed  by  the  taste  of 
a  warm,  salty  fluid  in  the  mouth,  which  proves  to  be 


HEMORRHAGE  617 

blood.  The  quantity  lost  at  a  time  is  usually  slight. 
The  blood  is  bright  red  and  frothy,  from  being  mixed  with 
air-bubbles.  If  a  large  vessel  is  ruptured,  the  quantity 
may  be  sufficiently  great  to  flood  the  respiratory  passage, 
and  death  results  from  asphyxia. 

The  usual  immediate  treatment  is  rest  in  bed,  generally 
with  the  shoulders  elevated,  and  plenty  of  fresh  air.  The 
patient  should  be  out-of-doors  or  by  an  open  window.  If 
he  is  in  a  room,  the  temperature  should  usually  be  as  low 
as  can  be  obtained.  Movement  is  limited,  but  not  entirely 
prohibited.  An  ice-bag  is  sometimes  applied  over  the 
affected  part,  but  more  often  is  found  to  increase  the  ten- 
dency to  cough.  Morphin  (yV  to  i  grain)  is  generally  or- 
dered, as  it  helps  to  reduce  the  cough  and  quiet  the  patient. 
Hemostatics  are  not  much  given,  nor  are  astringent  inhala- 
tions usually  considered  of  value.  Ice  to  suck  takes  away 
the  taste  of  blood  and  diverts  the  patient's  mind.  No  stim- 
ulants are  given.  The  diet  is  kept  low  (milk  and  eggs)  for 
a  day  or  two.  Movement  and  exercise  are  resumed  with 
caution — usually  not  before  twenty-four  hours  have 
elapsed.  If  the  hemorrhages  tend  to  recur,  gelatin  is 
frequently  given  in  the  diet. 

Hemoptysis,  caused  by  venous  congestion,  is  coughed  up 
a  little  at  a  time  and  mixed  with  expectoration.  A  con- 
siderable quantity  may  be  lost  in  twenty-four  hours.  It 
is  not  an  emergency,  but  one  of  the  symptoms  of  a  disease, 
and  treatment  is  influenced  by  the  underlying  cause. 

Rupture  of  an  aneurysm  into  the  lung  causes  death  in  a 
few  minutes  from  the  flooding  of  the  lungs  and  respiratory 
passages  with  blood,  as  well  as  from  syncope  from  the 
loss  of  blood.  Bright  red  blood  pours  from  the  mouth  and 
nose  and  no  treatment  is  possible. 

Hemoptysis  caused  by  injury  is  grave  or  mild,  according 
to  the  extent  of  the  injury.  In  mild  cases  the  treatment 
consists  in  absolute  rest,  repair  of  the  injury,  and  the  local 
application  of  an  ice-bag.  When  an  injury  is  severe,  as  in 
perf oration  of  the  lung  by  a  gunshot,  it  is  generally  fatal. 

Hemorrhage  from  the  Nose  (Epistaxis). — The  most 
common  cause  of  nosebleed  is  a  slight  violence  to  a  weak- 
walled  vessel  in  the  nose,  as  in  blowing  the  nose  with  too 


618        NURSING    IN    ACCIDENTS   AND    EMERGENCIES 

much  force;  it  may  also  occur  after  an  operation  on  the 
nares  or  tonsils,  or  spontaneously  in  the  course  of  scurvy 
or  purpura. 


Fig.   193. — Catheter  for  drawing   plug  into    the   posterior    nares 

(Morrow). 


Fig.  194. — Showing  the  method  of  drawing  a  plug  into  the  posterior 
nares  by  the  aid  of  Bellocq's  cannula  (Morrow). 

For  a  mild  attack  the  patient  is  laid  flat  on  the  back,  and 
cold,  usually  in  the  form  of  compresses,  applied  to  the 


HEMORRHAGE 


619 


nape  of  the  neck  and  over  the  nose.  In  severe  cases  the 
nares  may  be  sprayed  with  an  astringent  or  mild  styptic 
(vinegar  and  water,  1  ounce  to  1  pint,  or  adrenalin  chlorid, 
1  :  10,000  to  1  :  5000),  or  plugged  with  strips  of  sterile 
gauze.  The  hemorrhage  is  usually  from  the  anterior 
nares. 

Bleeding  after  an  operation  on  the  posterior  nares 
is  often  difficult  to  control.  Ice  to  suck,  cold  applications 
over  the  nose  and  to  the  nape  of  the  neck,  are  the  usual 
remedies  first  tried.  Styptics  may  be  applied  to  the  spot, 


Fig.  195. — The  posterior  nasal  plug  in  place  (Morrow). 

if  it  can  be  reached,  or  used  in  the  form  of  spray.  Those 
most  used  are  adrenalin  chlorid  (1  :  10,000  to  1  :  5000), 
tannic  acid  (20  to  50  per  cent.),  or  persulphate  of  iron. 
In  some  cases  it  is  necessary  to  plug  the  posterior  nares. 
A  plug  of  sterile  gauze  or  cotton  is  introduced  in  the 
following  way: 

A  fine  soft-rubber  catheter  is  threaded  with  a  double 
piece  of  stout  linen  thread.  The  catheter  is  passed  through 
the  nostril  and  by  the  pharynx,  into  the  mouth.  To  pass 
the  catheter  push  the  tip  of  the  nose  upward  and  direct 


(520        NUISINO   IN   ACCIDENTS   AND   EMERC.ENC1KS 

the  catheter  straight  backward  into  the  passage  exposed. 
The  threads  are  seized  and  tied  securely  around  the  plug, 
leaving  an  end  about  six  inches  long  free.  The  catheter  is 
then  withdrawn,  carrying  the  one  end  of  the  thread  with 
it;  the  plug  is  guided  into  the  posterior  nares  by  a  finger 
inserted  into  the  mouth,  and  pulled  firmly  into  place  by 
the  string  through  the  nostril.  The  anterior  nares  are 
then  packed  with  gauze.  At  the  end  of  twenty-four  hours 
the  packing  is  removed  and  the  nose  gently  douched  to 
soften  the  plug  and  prevent  it  adhering.  Traction  is 
then  made  on  the  string  in  the  mouth  and  the  plug  removed. 

Bleeding  may  continue  after  the  plug  is  inserted,  and  be 
concealed  by  the  application.  Any  change  in  the  pulse, 
and  such  sj'mptoms  as  pallor  and  yawning,  must  be 
promptly  reported. 

Bleeding  from  the  throat  may  result  from  severe  slough- 
ing, as  in  cases  of  scarlatina  anginosa,  or  follow  excision  of 
the  tonsils.  The  blood  may  escape  by  the  mouth  or  nose. 
If  much  is  swallowed,  it  is  usually  vomited.  Enough  may 
be  swallowed  to  give  the  stools  a  tarry  appearance.  The 
treatment  consists  in  giving  ice  to  suck,  ice-cold  or  as- 
tringent sprays,  or  the  direct  application  of  styptics, 
adrenalin  chlorid,  tannic  acid,  or  iron. 

Bleeding  from  the  ear  is  most  commonly  associated 
with  fracture  of  the  base  of  the  skull  (p.  640). 

Post-operative  Hemorrhage. — (See  p.  581.) 

Hemorrhage  Connected  with  Childbirth. — Hemorrhage 
occurring  during  pregnancy  or  during  labor,  before  the 
actual  birth,  is  known  as  antepartum  hemorrhage. 

The  cause  is  the  separation  of  the  small  portion  of  the 
placenta,  usually  the  result  of  an  accident,  such  as  a  fall; 
during  labor  it  is  commonly  due  to  malposition  of  the 
placenta.  The  hemorrhage,  which  is  usually  slight,  may 
be  revealed  or  concealed.  In  the  former  case  the  blood 
escapes  from  the  vagina;  in  the  latter,  the  only  symptoms 
are  the  physical  symptoms  of  hemorrhage.  If  the  bleed- 
ing is  excessive,  it  tends  to  separate  the  placenta  further 
and  may  cause  premature  labor. 

If  the  symptoms  are  not  severe,  rest  in  bed  for  a  few 
days  in  the  recumbent  position,  with  the  feet  elevated,  and 


HEMORRHAGE  621 

a  light  diet,  is  all  the  treatment  necessary.  If  the  symp- 
toms are  severe  or  the  hemorrhage  recurs  frequently, 
premature  labor  is  induced  by  mechanical  means.  An  ice- 
bag  may  be  ordered  over  the  probable  site  of  the  placenta. 
Packing  the  vagina,  unless  the  bleeding  point  can  be 
reached,  is  useless;  in  the  majority  of  cases  the  fetus 
intervenes  between  the  bleeding  point. 

Occurring  at  the  time  of  labor,  the  hemorrhage  may  be 
severe.  As  it  cannot  be  stopped  until  the  birth  is  over, 
the  treatment  consists  in  hurrying  the  labor  as  much  as 
possible.  No  styptics  can  be  given  until  the  uterus  is 
empty,  when  the  hemorrhage  will  probably  be  arrested  by 
the  natural  contraction  of  the  uterus.  The  patient's 
strength  is  spared  in  every  way. 

Hemorrhage  after  the  birth  of  the  fetus  is  called  post- 
partum  hemorrhage.  Occurring  at  the  time  of  labor,  it  is 
primary;  at  any  time  after  the  uterus  has  been  contracted, 
secondary. 

The  cause  is  usually  failure  of  the  uterus  to  contract 
(primary)  or  to  remain  contracted  (secondary),  due  either 
to  retention  of  a  portion  of  the  placenta  or  of  the  mem- 
branes, or  to  uterine  inertia.  Hemorrhages  may  also  occur 
from  accidents  to  the  uterus,  such  as  rupture,  or  from  lacer- 
ation at  some  point  of  the  birth-canal.  The  hemorrhage 
may  be  revealed  or  concealed.  In  the  former  the  blood 
escapes  by  the  vagina,  sometimes  gradually,  more  fre- 
quently in  a  sudden  enormous  rush.  Until  the  uterus 
contracts,  the  large  blood-vessels  or  sinuses,  which  have 
been  exposed  by  the  separation  of  the  placenta  from  the 
uterine  walls,  are  left  widely  dilated.  The  rush  of  blood 
may  be  so  great  that,  if  uncontrolled,  life  may  be  lost  in  a 
few  minutes.  The  physical  symptoms  of  hemorrhage 
are  marked  and  develop  abruptly.  Through  the  abdomi- 
nal wall  the  uterus  is  felt  like  an  inflated  balloon,  instead 
of  the  hard,  contracted  mass  it  should  represent. 

All  treatment  is  directed  toward  exciting  uterine 
contractions.  A  hot  intra-uterinc  douche  (120.2°  F.)  of 
sterile  water  or  normal  salt  solution  is  given,  at  the  same 
time  the  abdomen  is  vigorously  kneaded.  Ergot  (ergotin, 
2  to  5  grains)  is  given  by  hypodermic.  Contractions 


622       NUliSING   IN   ACCIDENTS   AND   EMERGENCIES 

have  been  excited  in  an  emergency  where  nothing  was 
at  hand  by  a  pail  of  cold  water  thrown  over  the  abdomen. 
If  fragments  of  the  placenta  or  membranes  are  retained, 
they  are  removed  by  hand.  The  hand  moved  forcibly 
around  the  internal  wall  of  the  uterus  may  also  excite 
contractions.  The  necessity  for  absolutely  strict  asepsis 
must  not  be  lost  sight  of,  however  great  the  emergency. 
In  all  labor  cases  the  hot  douche  with  sterile  apparatus 
should  be  ready  to  hand.  It  is  impossible  to  foresee  when 
it  may  be  required.  When  the  uterus  is  well  contracted, 
a  pad  is  placed  over  the  fundus  and  an  abdominal  binder 
firmly  applied.  The  usual  after-treatment  in  cases  of 
hemorrhage  will  be  necessary.  The  pulse  must  be  closely 
watched.  If  it  rises  above  80,  the  binder  should  be  un- 
done and  the  abdomen  again  kneaded  until  the  uterus  is 
felt  hard  and  firm. 

Hemorrhage  from  a  Ruptured  Fallopian  Tube. — The 
cause  is  the  development  of  the  embryo  in  one  of  the  tubes 
leading  from  the  uterus,  instead  of  on  the  wall  of  the  uterus. 
When  the  tube  can  extend  no  further,  it  ruptures,  causing 
bleeding  into  the  peritoneal  cavity.  The  hemorrhage  may 
be  entirely  concealed  or  partially  revealed,  a  small  trickle 
of  blood  escaping  by  the  vagina.  Sudden  pain  and  syncope 
and  the  symptoms  of  shock  are  the  usual  chief  indications. 
Though  the  actual  hemorrhage  is  slight,  the  condition 
is  a  very  grave  one,  recovery  depending  on  prompt  opera- 
tive treatment.  Septic  peritonitis  is  a  common  complica- 
tion from  the  discharge  of  blood  and  the  contents  of  the 
sac  into  the  peritoneal  cavity. 

Hemorrhage  from  the  kidneys  or  part  of  the  urinary 
tract  is  recognized  by  the  presence  of  blood  in  the  urine 
(hematuria) .  (See  Urine,  Chap.  VII.)  It  may  be  due  to 
injury  or  disease  of  the  organs,  or  to  the  action  of  irri- 
tant or  corrosive  poisons. 

The  cause  of  the  condition  is  treated.  The  quantity 
of  blood  lost  is  not  sufficient  to  cause  physical  symptoms. 
An  accident  involving  the  pelvis,  such  as  fracture  of  the 
pelvis  (p.  641),  is  frequently  complicated  by  internal 
hemorrhage.  The  condition  is  generally  associated  with 
profound  shock.  Blood  may  escape  from  the  rectum  or  be 


HEMORRHAGE  623 

mixed  with  the  urine,  which  should,  in  these  cases,  always 
be  carefully  saved  for  examination. 

Cerebral  Hemorrhage. — (See  Paralysis,  p.  719.) 

Hemorrhage  Due  to  Fracture  of  the  Base  of  the  Skull. 
—(See  Fracture  of  Base  of  Skull,  p.  640.) 

Spontaneous  Hemorrhage. — Setting  on  one  side  the 
subcutaneous  hemorrhages  already  described  as  character- 
istic of  certain  diseases,  spontaneous  hemorrhage  is  usually 
associated  with  hemorrhagic  purpura,  scurvy,  or  the  con- 
dition known  as  hemophilia. 

Hemorrhagic  purpura  is  a  disease  of  unknown  origin; 
at  the  present  day  it  is  considered  to  be  not  un- 
likely an  infection.  It  is  characterized  by  a  profuse 
petechial  eruption  and  hemorrhages  from  the  mucous' 
membranes;  the  latter  are  frequently  so  profuse  as  to 
threaten  life.  Accompanying  symptoms  are  malaise  and 
moderate  fever.  In  very  severe  cases  death  takes  place 
from  exhaustion  and  loss  of  blood.  Generally  the  attack 
lasts  about  two  weeks.  The  subsequent  anemia  is  often 
persistent. 

The  usual  prompt  treatment  for  hemorrhage  will  be 
necessary.  The  patient  is,  of  course,  confined  to  bed. 
The  stools  must  be  watched  for  traces  of  blood.  Rest  in 
bed,  fresh  air,  nourishing  diet,  and  iron  for  the  anemia 
comprise  the  general  treatment  during  convalescence. 
Gelatin  or  calcium  chlorid  are  frequently  ordered  as  pre- 
ventives against  further  attacks  of  hemorrhage. 

In  young  anemic  girls  spontaneous  hemorrhages  from 
the  nose,  stomach,  or  intestines  may  occur  from  time  to 
time,  usually  about  the  monthly  period,  and,  unless  in 
excess,  are  not  necessarily  alarming.  If  severe,  the  attack 
is  treated  on  the  lines  already  indicated. 

Hemorrhage  of  Scurvy. — Patients  suffering  from  scurvy 
are  likewise  liable  to  spontaneous  hemorrhages,  generally 
from  the  stomach  or  intestines,  which  are  treated  by  the 
usual  methods.  As  the  disease  is  caused  by  a. diet  de- 
ficient in  fresh  vegetables  or  milk,  the  diet  is  an  important 
part  of  the  treatment  (Chap.  XXIII).  The  mouth  should 
receive  special  care ;  the  gums  bleed  easily,  and  the  breath 
has  a  fetid  odor.  An  antiseptic  mouth-wash  should  be 


024        NURSING   IN   ACCIDENTS   AND    EMERGENCIES 

used  frequently,  especially  before  feeding.  Fresh  air  and 
good  hygiene  are  important  factors. 

Hemophilia,  or  bleeder's  disease,  is  generally  hereditary, 
and  the  family  history  suggests  the  condition.  As  a  rule, 
it  occurs  in  males,  but  is  transmitted  through  the  females 
of  a  family.  The  cause  is  unknown.  The  characteristic 
symptom  is  persistent  bleeding,  occurring  either  spon- 
taneously or  after  slight  injuries. 

The  disease  is  considered  incurable — few  bleeders  grow 
up.  A  few  are  said  to  outgrow  the  condition.  Patients 
with  a  family  history  of  hemophilia  are  advised  to  lead 
lives  with  as  little  exposure  to  injury  or  overexcitement  as 
possible,  and  should  not  undergo  operations  if  they  can 
possibly  be  avoided. 

Hemorrhage  from  so  slight  a  cause  as  the  drawing  of  a 
tooth  may  prove  so  persistent  as  to  cause  death  from 
exhaustion. 

The  attack  of  hemorrhage  is  controlled  by  the  usual 
methods,  but  is  often  very  intractable,  breaking  out  again 
and  again  after  the  vessel  has  been  closed  by  pressure,  the 
application  of  styptics,  etc.  Hemostatics  are  generally 
given  internally  at  the  time  of  the  hemorrhage.  A  course 
of  gelatin  or  calcium  chlorid  is  frequently  ordered. 

PERFORATION 

By  perforation  is  generally  understood  a  complete  rup- 
ture at  one  point  in  the  wall  of  the  intestines  or  the  stom- 
ach (the  latter  is  less  common),  resulting  in  escape  of 
the  contents  of  that  portion  of  the  alimentary  tract  into 
the  peritoneum.  Perforation  may  occur  as  the  result  of 
direct  injury;  after  an  operation  on  the  intestines  from 
sloughing  of  the  tissue;  and,  the  most  usual  cause,  from 
the  burrowing  of  an  ulcer  through  the  wall  of  the  intestine 
or  stomach. 

The  symptoms  are  sudden  pain  (not  always  present), 
abdominal  distention  (tympanites'),  sudden  fall  of  tempera- 
ture if  it  has  previously  been  elevated,  with  rapid,  feeble 
pulse  and  marked  symptoms  of  shock. 

The  treatment  is  instant  operation.  While  surgical 
aid  is  being  obtained  the  patient  should  be  kept  at  abso- 


PERFORATION  625 

lute  rest  in  the  recumbent  position,  with  the  head  low, 
and  external  heat  applied.  If  a  stimulant  is  ordered  it  is 
usually  strychnin  and  is  given  by  hypodermic.  Nothing 
is  given  by  mouth  and  all  previous  treatment  is  stopped. 

The  dangers  of  perforation  are  fatal  shock  and  septic 
peritonitis.  The  latter  develops  rapidly  from  decompo- 
sition of  the  food  substances,  which  have  escaped  into  the 
cavity  of  the  peritoneum.  It  is  in  order  to  avoid  this 
complication  that  prompt  operation  is  necessary. 

The  operation  consists  of  irrigation  of  the  peritoneum 
and  repair  of  the  perforation.  After  the  operation  mor- 
phin  is  usually  ordered  and  the  alimentary  tract  kept  at 
absolute  rest  for  three  or  more  days.  For  the  same  time 
all  movement  of  the  body  is  forbidden.  Fluid  diet  is 
then  begun  in  small  quantities.  The  bowels  are  relieved 
by  enemata  and  all  griping  laxatives  avoided. 

40 


CHAPTER  XVIII 

NURSING  IN   ACCIDENTS   AND   EMERGENCIES 

(Continued) 

Fractures:  Varieties;  Union;  Immediate  Treatment;  Surgical 
Treatment;  Pott's  Fracture;  Colles'  Fracture;  Fractures  of  Ribs; 
Skull — Vault,  Base;  Jaw;  Pelvis;  Spine.  Dislocations:  General 
Treatment;  Jaw,  Finger;  Sprains;  Wounds:  Varieties;  Healing  of ; 
Treatment;  Dressings — Complications:  Inflammation;  Infection; 
Abscess;  Blue  Pus;  Cellulitis;  Slough;  Gangrene;  Embolism — Special 
Infections:  Erysipelas,  Scarlet  Fever,  Tetanus. 

FRACTURES 

By  a  fracture  is  understood  the  breaking  of  a  bone. 
It  is  commonly  described  as  a  "  break  in  the  continuity  of 
a  bone."  A  fracture  is  caused  by  direct  or  indirect  violence 
or  by  the  sudden  contraction  of  powerful  muscles. 

Violence  is  said  to  be  direct  when  it  causes  a  lesion  at  the 
immediate  site  of  injury,  as  in  a  fracture  caused  by  a  blow 
or  a  gun-shot  wound,  etc. 

In  indirect  violence  the  lesion  occurs  at  a  distance  from 
the  immediate  site  of  injury.  Thus,  a  fracture  of  the 
clavicle  may  be  caused  by  a  fall  on  the  shoulder.  An 
example  of  a  fracture  due  to  muscular  contraction  is  that 
of  a  fractured  patella  in  consequence  of  a  fall  on  the  feet, 
and  directly  due  to  the  instinctive  strong  contraction  of 
the  quadriceps  muscle  in  the  common  tendon  of  which 
the  patella  is  contained. 

Varieties. — According  to  the  direction  of  the  fracture, 
it  is  described  as  transverse,  oblique,  or  longitudinal. 

In  long  bones  the  fracture  may  occur  at  the  shaft 
(diaphysis),  at  the  ends  (epiphysis),  at  the  head,  or  at  the 
neck.  For  convenience,  the  shaft  of  the  long  bones  of  the 
extremities  is  usually  described  in  three  parts — the  upper, 
middle,  and  lower  thirds.  A  fracture  at  the  epiphysis 
separates  the  head  from  the  shaft. 

626 


FRACTURES  627 

Fractures  at  the  neck  of  a  long  bone  are  described  as 
intracapsular,  if  occurring  inside  the  capsule  that  incloses 
the  joint;  or  extracapsular,  if  occurring  outside  the  capsule. 
Intracapsular  fractures  are  liable  to  result  in  ankylosis, 
or  permanent  rigidity  of  the  joint. 

Symptoms. — The  characteristic  symptoms  of  a  frac- 
ture are:  Sudden  pain,  in  connection  with  a  history  of 
violence,  deformity,  abnormal  movement,  swelling  and  dis- 
coloration of  the  surrounding  tissues  (due  to  extravasa- 
tion of  blood),  crepitus  or  a  grating  sensation  if  the  frac- 
tured ends  are  moved  on  each  other,  and  interference  with 
function.  The  function  of  the  bones  of  the  extremities 
is  support  and  movement.  When  such  a  bone  is  frac- 
tured, it  cannot  be  used  to  support  the  body,  and  volun- 
tary movement  below  the  seat  of  fracture  is  either  lost  or 
restricted.  In  fractures  of  the  extremities  the  injured 
limb  is  frequently  altered  in  length  in  comparison  with 
the  sound  limb;  if  the  fracture  occurs  at  or  near  a 
joint,  there  is,  usually,  a  characteristic  dislocation  of  the 
joint. 

Fractures  of  the  brain,  pelvis,  or  spine  are  complicated 
by  injuries  to  the  adjacent  structures,  giving  rise  to 
special  symptoms. 

Classification. — Fractures  are  divided  into  two  chief 
groups — simple  or  closed,  and  compound  or  open. 

In  a  simple  or  closed  fracture  the  injury  is  subcutaneous, 
the  external  tissues  protecting  it  from  contact  with  the 
air.  Flesh  wounds  may  exist,  but  do  not  form  a  channel  of 
communication  between  the  fracture  and  the  surface.  As 
long  as  a  fracture  remains  simple,  it  is  protected  from 
infection. 

In  a  compound  or  open  fracture  there  is  also  an  open 
flesh  wound,  forming  a  direct  channel  of  communication 
between  the  fracture  and  the  surface.  The  fractured 
bone  can  be  reached  through  the  wound.  A  compound 
fracture  is  usually  due  to  direct  violence. 

Besides  the  two  chief  groups,  fractures  are  also  sub- 
divided according  to  certain  characteristics. 

Greenstick  Fracture. — This  is  one  in  which  the  bone  is 
bent  and  only  partially  broken.  Greenstick  fractures 


628        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 


are  common  in  the  long  bones  of  children,  the  bones  being 

soft  and  easily  bent. 

Comminuted  Fractures. — A  fracture  in  which  the  bone 

is  splintered  into  several  pieces.     A  comminuted  fracture 

is  more  often  also  compound. 
Impacted  Fractures. — A  fracture  in  which  the  broken 

ends  are  forcibly  driven  together,  or  impacted,  at  the  time 

of  injury.  Impacted  fractures  are  usually  simple,  and 
occur  chiefly  in  long  bones  as  the 
result  of  indirect  violence,  as,  for 
example,  in  a  fall  where  the 
weight  of  the  body  is  received  on 
the  outstretched  limb. 


Fig.  196. — Compound  fracture 
("American  Illustrated  Medical 
Dictionary  "). 


Fig.  197. — Partial  or  greenstick 
fracture  of  the  radius. 


Multiple  Fractures. — A  fracture  of  one  bone  in  two  or 
more  separate  places. 

Complicated  Fractures. — A  fracture  is  said  to  be  com- 
plicated if  it  is  associated  with  serious  injury  to  some 
important  adjacent  structure,  such  as  the  rupture  of  a 
large  blood-vessel  or  injury  to  an  internal  organ. 

Depressed  Fractures. — A  fracture  in  which  the  broken 
fragment  is  forcibly  driven  inward  against  the  underlying 
structures.  Depressed  fractures  are  the  result  of  direct 


FRACTURES 


629 


violence  and  are  frequently  compound.     They  occur  in 
fractures  of  the  skull  and  upper  jaw. 

Physical  Symptoms. — Besides  the  local  symptoms  and 
those  arising  directly  from  injury  to  important  structures, 
as,  for  example,  compression  of  the  brain,  a  fracture  is 
usually  accompanied  by  certain  physical  symptoms,  more 
or  less  marked  according  to  the  circumstances  of  the 
accident  and  the  condition  of  the  general  health.  Some 
shock  is  always  present,  and  may  be  severe.  Slight  fever, 
malaise,  and  gastric  disturbances  are  generally  present 
during  the  first  few  days.  The 
condition  is  treated  by  rest,  quiet, 
a  purgative,  and  light  diet.  Severe 
shock  is  a  prominent  symptom 
in  fractures  of  the  pelvis  and  the 


Fig.  198. — Comminuted  frac- 
ture of  the  tibia  ("  International 
Text-Book  of  Surgery  "). 


Fig.  199. — Impacted  fracture 
of     the    neck     of     the     femur 

(Da  Costa). 


skull.  In  alcoholic  subjects  mental  excitement  and  in- 
somnia are  common  symptoms.  They  are  usually  treated 
with  sedatives,  in  order  to  prevent  the  development  of 
delirium  tremens. 

The  Repair  of  Fractures. — The  time  allowed  for  the 
union  of  a  fractured  bone  varies  with  the  size  and  im- 
portance of  the  bone  and  its  position  in  the  body. 

A  fracture  of  a  bone  of  a  finger  will  unite  in  about  two 
weeks,  while  for  a  fracture  of  the  neck  of  the  femur,  a 


630        NURSING   IN   ACCIDENTS   AND   EMERGENCIES 


bone  that  has  to  bear  the  whole  weight  of  the  body,  from 

ten  to  twelve  weeks  are  allowed. 

Repair  of  a  fracture  takes  place  by  the  deposit  of  new 

bony  tissue,  to  which  the  name  callus  is  given.     The  first 

callus  is  temporary  or  provisional,  and  resembles  cartilage; 

it  first  forms  on  the  outside  of 
the  fractured  ends,  incasing 
them  like  a  natural  splint, 
and  later  between  the  broken 
fragments,  thus  forming  a 
temporary  union.  From  the 
provisional  callus  a  permanent 
callus  is  developed  between 
the  fractured  ends  of  the  bones, 
forming  what  is  known  as 
bony  union.  The  provisional 
callus  is  gradually  absorbed 


Fig.  200.— Callus  of  fracture 
(dog)  four  weeks;  commencing 
ossification  of  external  callus 
(Warren) . 


Fig.   201. — Appearance    of    the 
ends  of  fragments  (Da Costa). 


in  the  process  of  healing.  In  large  bones  about  twelve 
months,  it  is  considered,  is  required  before  the  permanent 
callus  is  as  strong  as  true  bone. 

In  some  instances  bones  fail  to  unite.     The  usual  causes 
are  imperfect  approximation,  either  by  careless  "  setting  " 


FRACTURES  631 

or  from  failure  to  keep  the  fragments  at  complete  rest, 
disease  of  the  bone,  or  suppuration. 

Imperfect  approximation  may  result  in  the  deposit  of 
fibrous  tissue  instead  of  bony  tissue  between  the  broken 
ends,  forming  what  is  known  as  fibrous  union.  This  is 
especially  liable  to  occur  in  fractures  of  the  patella  where 
a  fold  of  the  periosteum  is  apt  to  intervene  between  the 
divided  fragments.  Fibrous  union  is  useless  for  the  pur- 
pose of  bone  function.  Permanent  deformity  and  short- 
ening of  a  limb  are  also  results  of  imperfect  approxima- 
tion. Union  may  be  delayed  by  physical  conditions  which 
affect  the  health  of  the  patient.  For  malunion  the  treat- 
ment usually  is  to  break  the  bone  afresh  and  reset  the 
fracture. 

For  cases  of  delayed  union  a  surgical  operation  is  fre- 
quently performed,  and  the  fragments  either  wired  or 
screwed  together. 

In  aged  people  bony  union  does  not  commonly  take- 
place.  If  the  patient  recovers  from  the  shock,  he  is 
usually  moved  out  of  bed  on  to  a  chair  as  soon  as  the 
symptoms  of  pain  and  inflammation  have  subsided,  other- 
wise he  may  become  bedridden.  Whenever  possible, 
such  patients  should  be  induced  to  learn  to  walk  with 
crutches. 

Other  complications  that  may  arise  from  a  fracture 
are  as  follows:  Extensive  sloughing  of  the  adjacent 
soft  tissues,  destruction  of  bone,  resulting  in  the  for- 
mation of  sequestra,  hemorrhage,  either  primary  or 
secondary  (see  Hemorrhage),  embolism  (see  Embolism), 
painful  callus,  caused  by  the  pinching  of  a  nerve,  and 
infections,  either  local,  causing  suppuration,  or  general, 
as  septicemia,  erysipelas,  and  tetanus.  As  in  all  violent 
accidents,  delirium  tremens  is  a  common  complication  in 
alcoholic  patients. 

TREATMENT  OF  FRACTURES 

Immediate  Treatment. — Wherever  a  fracture  occurs, 
temporary  means  should  be  taken  to  keep  the  part  at 
rest  until  surgical  help  can  be  obtained,  otherwise  in- 
judicious movement  will  increase  the  hemorrhage  and 


632        NURSING   IN    ACCIDENTS   AND   EMERGENCIES 

may  cause  serious  injury  to  the  adjacent  structures,  such 
as  rupture  of  a  large  blood-vessel,  or  convert  a  simple 
fracture  into  a  compound  one.  For  the  same  reasons 
no  attempt  should  be  made  by  the  bystanders  to  reduce 
or  "  set  "  the  fracture,  however  apparent  the  deformity; 
where  practical,  the  injured  member  may  be  elevated  and 
cold  applied  over  the  seat  of  the  fracture.  This  will  help 
to  control  the  hemorrhage,  check  the  inflammation,  and 
relieve  the  pain.  Very  frequently  it  is  necessary  to  transfer 
the  patient  before  surgical  aid  can  be  procured.  In  these 
cases  temporary  support  of  the  fracture  must  be  given. 

For  a  fracture  of  the  leg  (p.  288)  the  limb  may  be  ex- 
tended on  a  pillow  or  folded  coat,  in  as  straight  a  position 
as  can  be  obtained  without  force.  Outside  the  pad  so 
formed  temporary  splints  made  of  boards,  walking-sticks, 
rolled  newspapers,  etc.,  are  placed,  and  the  whole  tied 
securely  round  the  limb  immediately  above  and  below 
the  seat  of  fracture,  and  again  above  the  knee  and  round 
the  foot. 

A  fracture  of  the  forearm  may  be  treated  in  the  same 
way.  If  the  patient  must  walk,  the  elbow  should  be  flexed 
and  the  forearm  supported  in  a  sling.  In  a  fracture  of 
any  part  of  the  femur  the  patient  must  be  kept  perfectly 
flat  and  transferred  on  a  stretcher  or  board.  If  possible  to 
devise  a  temporary  splint,  it  should  be  applied  on  the 
outside  of  the  injured  member  and  extend  from  the  axilla 
to  beyond  the  foot.  It  should  be  kept  in  position  by 
ties  passing  round  the  body  and  round  both  lower 
extremities,  the  uninjured  leg  thus  acting  as  a  second 
splint.  A  board  must  be  kept  under  the  pelvis. 

A  fracture  of  the  upper  arm  is  usually  best  secured  by 
placing  a  flat  pad  between  the  arm  and  the  body,  and 
pinioning  the  arm  firmly  against  the  side  with  a  stout 
towel  secured  by  several  pins.  To  be  correct,  the  posi- 
tion should  be  comfortable.  If  there  is  deformity  about 
the  shoulder,  or  if  the  patient  must  walk,  the  forearm 
may  be  supported  in  a  sling.  Should  the  elbow  be 
affected,  a  temporary  splint  should  be  devised  and  applied 
on  the  inner  surface  of  the  elbow,  so  that  the  joint  is  kept 
extended. 


FRACTUKES  633 

In  a  fracture  of  the  clavicle,  usually  due  to  indirect 
violence  from  a  fall  on  the  shoulder  or  outstretched 
arm,  the  shoulder  is  dropped  and  the  patient's  head  is 
turned  to  the  injured  side;  he  cannot  raise  the  hand  to  his 
head.  He  should  lie  flat,  with  the  arm  extended  by  his 
side.  If  it  is  necessary  for  him  to  walk,  a  pad  should  be 
placed  in  the  axilla  and  the  hand  brought  over  and  held 
on  the  opposite  shoulder.  In  this  position  a  stout  towel 
is  pinned  round  the  body  over  the  affected  arm.  The 
elbow  should  be  supported  by  the  free  hand.  If  the 
movement  causes  pain  or  appears  to  increase  the  de- 
formity over  the  clavicle,  it  is  better  to  allow  the  arm  to 
hang,  fixing  it  to  the  side  with  a  broad  towel.  A  small 
pad  should  be  placed  in  the  axilla. 

If  a  rib  is  fractured,  the  patient  should  be  transferred 
with  as  little  movement  as  possible.  The  initial  injury 
may  be  slight,  but  injudicious  movement  may  result  in 
puncture  of  the  pleura  or  of  the  lungs  (see  below).  The 
local  pain  is  commonly  acute.  A  towel  pinned  firmly 
round  the  chest  will  help  to  minimize  the  movement  of 
the  chest-wall  in  the  act  of  breathing. 

In  compound  fractures  there  is  also  the  open  wound 
to  be  treated.  It  rarely  occurs  that  the  means  of  treating 
it  by  aseptic  methods  are  immediately  at  hand.  If  a 
sterile  dressing  can  be  had  or  devised,  as  by  boiling  a 
clean  handkerchief,  the  wound  can  be  temporarily  dressed. 
Otherwise  it  is  best  left  untouched,  loosely  covered  with 
the  cleanest  article  obtainable,  and  guarded  carefully,  as 
far  as  possible,  from  contact  with  soiled  clothing  or 
outside  matter,  particularly  from  contamination,  by  soil, 
since  in  soil  the  bacillus  of  tetanus  is  frequently  found. 

Should  it  be  necessary  to  remove  clothing,  the  injured 
limb  should  be  steadily  supported  above  and  below  the 
seat  of  fracture.  It  is  rarely  necessary  to  cut  away  and 
destroy  the  clothes.  In  removing  trousers  or  a  coat,  the 
uninjured  limb  must  first  be  divested;  the  garments  can 
then  be  drawn  over  the  injured  limb  with  a  minimum 
amount  of  movement  or  pain. 

In  the  suspected  fracture  of  the  skull  (especially  the 
base),  the  spine,  or  the  pelvis,  the  patient  should  be  placed 


634        NURSING   IN   ACCIDENTS   AND    EMERGENCIES 

in  bed  in  the  recumbent  position  with  as  little  movement  as 
possible.  To  raise  him,  a  sheet  or  blanket,  if  procurable, 
should  be  rolled  beneath  him,  by  the  four  corners  of  which 
he  can  be  lifted  on  an  improvised  stretcher.  The  clothing 
should  be  loosened,  but  no  attempt  made  to  remove  it 
until  expert  help  can  be  obtained.  Shock  is  always  a 
feature  of  such  accidents.  It  is  treated  by  the  recumbent 
position,  with  the  head  low  and  external  warmth.  Stimu- 
lants may  be  necessary  if  the  patient  is  in  extremis.  They 
must,  however,  be  given  with  caution,  as  they  increase 
the  hemorrhage. 

In  accidents  to  the  spine,  pain  and  sensation  of  all  kind 
will  probably  be  absent,  owing  to  the  paralysis  involved; 
none  the  less,  movement  may  greatly  aggravate  the  in- 
jury. 

In  a  fracture  of  the  pelvis  the  patient  can  neither  stand 
nor  sit.  If  such  an  injury  is  suspected,  the  thighs  should 
be  flexed  by  pillows  placed  below  the  knees,  and  cold  may 
be  applied  to  the  lower  part  of  the  abdomen. 

In  severe  injuries  to  the  skull  the  patient  is  gen- 
erally unconscious.  Cold  may  be  applied  to  the  head 
and  all  noise  and  bright  light  should  be  excluded. 
Should  a  patient  be  unconscious,  his  head  must  be  care- 
fully kept  turned  to  one  side.  The  reason,  of  course, 
is  that  already  emphasized — to  prevent  any  vomited 
matter  from  falling  into  the  larynx,  since  an  attack  of 
vomiting  is  a  common  accompaniment  of  reaction  from 
shock. 

Surgical  Treatment  of  Fractures. — The  local  treatment 
of  a  fracture  consists,  where  practical,  in  the  proper 
approximation  of  the  broken  ends  by  manipulation  or 
traction.  The  process  is  familiarly  known  as  "  setting 
the  bones."  If  the  deformity  is  great  or  there  is  spasm 
of  the  muscle,  it  is  frequently  necessary  to  administer 
an  anesthetic  in  order  to  reduce  the  fracture.  After  the 
reduction  of  a  fracture  in  the  shaft  of  a  bone  a  splint  that 
will  keep  the  fractured  fragments  in  proper  position  is 
applied.  Provided  the  part  is  at  rest  in  a  good  position, 
there  is  not  usually  any  necessity  to  hurry  in  the  setting 
of  a  simple  fracture.  A  day  or  even  two  is  frequently 


FRACTURES  035 

allowed  to  elapse  between  the  injury  and  the  reduction. 
(See  Splints,  etc.,  Chap.  VIII.) 

In  applying  a  splint  it  must  be  remembered  that  the 
joint  above  and  below  the  fracture  must  also  be  kept  at 
absolute  rest,  and  a  splint  large  enough  to  extend  gener- 
ously beyond  the  joints  should  be  selected.  As  a  rule, 
in  bandaging  the  splint  to  the  limb  the  bandage  is  applied 
above  and  below  the  seat  of  fracture,  leaving  the  injured 
area  free  from  pressure. 

Fractures  at  or  near  an  important  joint  are  fre- 
quently treated  by  extension  (p.  319),  either  with  or 
without  splints.  Extension  treatment  is  also  usually 
preferred  in  fractures  of  the  femur  higher  than  the  lower 
third.  The  patient  remains  in  bed.  If  the  mattress 
is  a  spring  mattress,  or  liable  in  any  way  to  sag,  it 
must  be  stiffened  with  fracture-boards  (p.  322);  if  the 
fracture  is  to  any  part  of  the  lower  extremity,  sagging 
of  the  mattress  may  interfere  with  proper  approxima- 
tion. 

Until  the  swelling  is  reduced,  cold,  usually  in  the  form 
of  the  suspended  ice-bag,  is  frequently  applied  over 
the  injury.  In  extensive  contusions  cold  is  contraindi- 
cated  (p.  121).  Blisters  frequently  form  over  the  con- 
tused area.  Generally  they  are  protected  from  breaking 
with  a  light  pad  of  cotton,  and  allowed  to  reabsorb. 
If  they  become  broken,  they  form  a  channel  for  infection, 
and  must  be  dressed  at  once  with  aseptic  methods. 

At  the  end  of  a  period  that  varies  with  the  extent  of  the 
injury  and  the  position  of  the  bone  in  the  body,  the  splints 
are  removed  and  replaced  by  a  stiff  bandage  or  a  plaster 
cast  (Chap.  VIII),  which  is  retained  until  union  is  per- 
fect. In  fractures  of  the  lower  extremity  the  patient  is 
then  usually  able  to  get  about  on  crutches. 

In  fractures  occurring  at  or  near  a  joint,  with  the 
exception  of  the  hip  and  the  vertebrae,  light  massage  and 
gentle  passive  movements  are  frequently  prescribed  as 
soon  as  the  preliminary  swelling  has  subsided,  in  order 
to  promote  absorption  of  inflammatory  products  and 
prevent  the  formation  of  adhesions. 

Two  fractures  very  frequently  met  with  are  known  as 


036        NURSING    IN   ACCIDENTS   AND    EMERGENCIES 


Pott's  fracture  and  Grilles'  fracture;  both  are  serious  acci- 
dents complicated  by  dislocation  of  an  important  joint. 

A  Pott's  fracture  is  a  fracture  of  the  fibula  just  above 
the  malleolus,  and  accompanied  either  by  fracture  of  the 
tip  of  the  inner  malleolus  (of  the 
tibia)  or  by  rupture  of  the  internal 
lateral  ligament.  There  is  a  charac- 
teristic dislocation  of  the  ankle,  turn- 
ing the  foot  outward  (eversiori).  On 
account  of  the  dislocation  of  the  ankle 
the  reduction  of  a  Pott's  fracture 
requires  special  care  and  is  usually 
performed  under  an  anesthetic.  It 
is  of  great  importance  that  a  correct 
position  should  be  maintained,  or  per- 
manent crippling  and  deformity  may 
result.  A  well-fitting  back  and  side 
splint  may  be  used,  or  a  Dupuytren 
straight  splint  may  be  preferred  (p. 
316).  After  a  couple  of  weeks  the 
splint  is  generally  replaced  by  a  plaster 
cast.  Light  massage  and  gentle  pas- 
sive movements  are  commonly  ordered 
at  an  early  date. 
Not  infrequently  a  Pott's  fracture  is  compound.  If 
suppuration  occurs,  ankylosis  of  the  ankle-joint  will 
probably  result. 

A  Colics'  fracture  is  a  fracture  of  the  lower  end  of  the 
radius,  accompanied  by  a  characteristic  dislocation  of  the 
wrist,  often  called,  from  its  appearance,  the  "  silver-fork  " 
dislocation.  It  is  caused  by  falling  on  the  outstretched 
hand.  The  hand  is  dislocated  backward  and  drops 
toward  the  ulnar  side.  The  broken  fragments  are  fre- 
quently impacted.  A  characteristic  symptom  is  an 
acutely  painful  spot  over  the  fracture. 

Reduction  of  the  dislocation  and  the  setting  of  the  frac- 
ture are  generally  done  under  an  anesthetic,  and  a  special, 
closely  fitting  splint  applied.  (See  Bond's,  Levis'  Splints, 
etc.)  Massage  and  gentle  passive  movements  are  gener- 
ally begun  early — sometimes  at  the  end  of  the  first  week. 


Fig.  202.  — Pott's 
fracture  ("  American 
Illustrated  Medical 
Dictionary  ")• 


FRACTURES 


637 


By  a  fracture  of  the  knee,  fracture  of  the  patella,  or 
knee-cap,  is  understood.  Frequently  it  is  caused  by  sudden 
violent  contraction  of  the  quadriceps  muscle,  as  in  saving 
from  a  fall.  Unless  bony  union  is  obtained,  permanent 
lameness  results.  Fibrous  union  is  a  not  infrequent  occur- 
rence, especially  where  the  periosteum  remains  intact; 
a  fold  of  the  periosteum  is  very  liable'  to  fall  between  the 
broken  fragments.  To  prevent  this,  it  is  often  necessary 
to  "  wire  "  the  patella,  or  the  broken  fragments  are  brought 
together  by  hooks,  known  as  Malgaigne's  hooks.  If 
operative  treatment  is  not  necessary,  a  posterior  splint 


Fig.  203. — Cellos'  fracture,  showing  characteristic  deformity 
(silver-fork  deformity)  at  the  wrist,  due  to  backward  displacement 
of  the  lower  fragment  (Levis). 

is  applied,  the  fragments  are  approximated,  and  held  in 
position  by  strips  of  adhesive  plaster  adjusted  above  and 
below  the  seat  of  fracture,  as  in  a  tortuous  bandage  (p. 
292),  and  fastened  to  the  posterior  splint;  above  the 
plaster  a  figure-of-8  bandage  is  applied.  The  extremity 
is  then  placed  on  an  inclined  plane,  the  leg  extended,  and 
the  thigh  flexed. 

Light  massage  of  the  knee-joint,  with  gentle  passive 
movements,  is  frequently  ordered  at  an  early  stage  of 
convalescence. 

A  fractured  clavicle  (see  above)  is  usually  treated  by  the 
application  of  a  Yelpeau  bandage  or  by  Sayre's  method 


638        NUKSING    IN    ACCIDENTS   AND   EMERGENCIES 

of  adhesive  strapping  (p.  325).  The  arm  is  kept  in 
position  for  three  weeks,  but  if  the  physical  condition 
permits,  the  patient  is  allowed  to  walk  and  move  about 
freely.  In  some  instances  these  methods  fail  to  obtain 
perfect  approximation.  The  treatment  then  consists 
in  keeping  the  patient  flat  on  the  back  on  a  mattress 
stiffened  by  fracture-boards,  with  the  arm  straight  to  the 
side.  A  pad  is  placed  in  the  axilla  to  raise  the  shoulder, 
and  the  position  is  maintained  by  sand-bags  placed  on 
either  side  of  the  body.  A  small  sand-bag  is  also  placed 
against  the  head  on  the  affected  side,  to  correct  the 
rotation  toward  the  shoulder.  A  second  small  pad  may 
be  necessary  between  the  shoulder-blades  to  keep  the 
shoulder  back.  The  fixed  position  is  one  of  considerable 
discomfort;  great  care  is  necessary  to  prevent  the  forma- 
tion of  a  bed-sore. 

Fractured  ribs  are  treated  by  strapping  the  affected 
side  or  by  the  application  of  a  broad  bandage  to  the 
chest  (p.  325).  Coughing  and  dyspnea  are  symptoms  of 
injury  to  the  pleura.  If  accompanied  by  blood-stained 
expectoration  and  the  symptoms  of  shock,  the  lung  has 
probably  been  damaged.  A  fracture  puncturing  the  lung 
is  a  compound  fracture,  although  there  may  be  no  external 
wound.  Through  the  lung  the  broken  fragments  are  in 
communication  with  the  outer  air.  The  pleura  is  a  closed 
cavity;  a  fracture  involving  only  the  pleura  is  complicated, 
but  not  compound. 

Complications  that  may  arise  from  a  fractured  rib  are 
pleurisy,  pneumonia,  hemothorax,  empyema,  and  pneumo- 
thorax.  A  rise  of  temperature,  with  quickened  respira- 
tion, cough,  and  expectoration,  are  symptoms  to  be 
promptly  noted. 

The  skull  may  be  fractured  at  the  vault  or  the  base. 
Fractures  of  the  vault  are  due  to  direct  violence.  When 
simple,  and  if  not  depressed,  they  may  easily  be  overlooked; 
their  importance  lies  in  the  injury  they  may  cause  to  the 
underlying  structures,  the  meninges,  or  the  brain.  Unless 
there  are  symptoms  of  injury  to  the  brain  or  compression, 
no  treatment  is  considered  necessary.  With  these  acci- 
dents there  is  usually  some  concussion.  A  purgative  is 


FRACTURES 


639 


administered,  and  the  patient  is  kept  in  bed  as  long  as  the 
symptoms  last. 

A  compound  fracture  of  the  vault  is  generally  depressed 
and  frequently  comminuted;  in  some  cases  the  bone  is 
also  punctured.  It  is  a  serious  accident,  both  on  account 
of  the  immediate  injury  to  the  brain  and  the  danger  of 
subsequent  inflammation  or  infection  involving  the  brain. 
If  the  fracture  is  depressed,  there  may  be  symptoms  of 
brain  compression,  of  which  the  first  symptoms  are  vom- 
iting, headache,  restlessness,  a  slow,  full  pulse,  facial  con- 
gestion, and  contracted  pupils.  Later  symptoms  are 


Fig.  204. — Comminuted  fracture  of  the  skull  (Hoffa). 

unconsciousness,  stertorous  breathing,  rise  of  temperature, 
slow  pulse  with  high  tension,  dilated  pupils,  profuse  per- 
spiration, and  paralysis  with  involuntary  evacuations. 
Epileptiform  convulsions  may  occur,  or  profound  coma, 
passing  into  collapse.  Retention  of  urine  is  common,  and 
should  be  relieved  by  the  catheter.  Some  concussion  is 
commonly  present. 

Shock  may  be  a  prominent  symptom,  even  in  cases 
where  the  local  injury  is  not  great,  and  is  treated  by  the 
recumbent  position  and  external  warmth.  Stimulants 
are  avoided  as  much  as  possible.  A  quickly  acting  pur- 
gative is  usually  given  at  once  (croton  oil,  1  to  3  minims). 


640        NURSING    IN    ACCIDENTS   AND   EMERGENCIES 

If  the  patient  is  drunk,  lavage  is  generally  performed.  The 
surrounding  area  of  the  head  is  shaved  and  washed.  The 
wound  is  thoroughly  cleansed,  the  clots  and  every  particle 
of  foreign  matter  patiently  removed.  In  many  cases  the 
wound  can  be  brought  together  with  stitches,  leaving, 
as  a  rule,  an  opening  for  drainage.  For  depressed  fracture 
or  fractures  in  which  the  bone  is  punctured,  a  surgical 
operation  is  necessary.  Depressed  fractures  are  elevated; 
an  injured  bone  is  removed  by  trephining. 

Complications,  usually  fatal,  of  a  compound  fracture  of 
the  vault  are  septic  inflammation,  which  generally  involves 
the  meninges,  and  the  formation  of  a  thrombus  in  one  of 
the  cerebral  vessels. 

The  patient  should  be  nursed  in  a  quiet  room,  with  the 
light  shaded  and  all  disturbances  or  excitement  avoided. 
The  head  of  the  bed  is  elevated,  or  the  head  may  be  raised 
on  pillows.  The  most  important  point  is  to  keep  the  wound 
aseptic,  and  to  prevent  risk  of  hemorrhage  from  sudden 
movements.  The  diet  is  liquid  until  convalescence  is 
established.  The  bowels  must  be  kept  active.  Symp- 
toms for  which  special  watch  should  be  kept  are  twitchings 
of  the  muscles,  convulsions,  paralysis,  and  sudden  changes 
of  the  pulse  or  temperature.  The  blood-pressure  is  an  im- 
portant indication  of  the  condition  in  all  cases  of  brain 
compression;  in  nursing  such  cases  a  nurse  may  be  ex- 
pected to  take  the  pressure  with  the  sphygmomanometer 
(p.  204). 

Fractures  of  the  base  of  the  skull  are  the  result  of  indirect 
violence,  commonly  a  fall.  The  immediate  symptoms 
are  those  of  shock  and  violent  concussion,  and  may  be 
mistaken  for  drunkenness.  Symptoms  of  compression 
of  the  brain  develop  rapidly,  as  just  described.  In  severe 
injuries  consciousness  is  not  regained  from  the  first  con- 
cussion, and  the  patient  passes  into  a  profound  coma 
which  ends  fatally  in  a  few  hours.  Characteristic  diagnostic 
symptoms  are  a  discharge  of  blood  or  clear  fluid  (cerebral) 
from  the  ears,  nose,  or  mouth,  and  unequal  dilatation  of  the 
pupils,  that  on  the  affected  side  being  widely  dilated. 
Later  there  is  ecchymosis  (discoloration  due  to  subcu- 
taneous escape  of  blood)  round  the  orbits  and  over  the 


FRACTURES  641 

mastoid  process,  and  suffusion  of  blood  in  the  conjunctiva. 
It  must  not  be  overlooked  that  external  traces  of  blood 
may  be  due  merely  to  local  injuries. 

The  fracture  is  simple;  blood  or  fluid,  however,  escaping 
by  the  cavities,  forms  a  channel  of  communication  between 
the  injury  and  the  outer  air,  and  may  be  the  means  of  in- 
fection. Where  the  ears  discharge,  the  external  ear  or 
nostril  should  be  carefully  cleansed  by  aseptic  methods 
and  the  openings  lightly  plugged  with  sterile  absorbent 
cotton. 

The  physical  symptoms  are  treated  with  rest  in  the 
recumbent  position,  in  a  darkened  room,  and  an  ice-bag 
applied  to  the  side  or  back  of  the  head.  For  threatened 
collapse  stimulants  are  given,  but  are  avoided  otherwise. 
Complications  to  be  apprehended  are  inflammation  of  the 
brain  or  meninges,  and  cerebral  thrombus.  Persistent 
coma  with  high  temperature  are  regarded  as  fatal  symp- 
toms. If  recovery  takes  place,  the  mental  faculties  are 
frequently  impaired. 

Fracture  of  an  orbit  may  result  from  indirect  violence, 
and  is  serious  on  account  of  the  risk  of  injury  or  inflamma- 
tion to  the  eye,  the  optic  nerve,  or  the  adjacent  portion 
of  the  brain. 

The  patient  is  kept  at  complete  rest  in  the  recumbent 
position.  The  light  is  shaded,  and  the  use  of  the  eye 
forbidden  until  convalescence  is  established.  The  local 
treatment  is  according  to  the  extent  of  the  injury;  an 
oculist  should  be  consulted.  Constant  cold  compresses 
are  frequently  ordered  to  the  eye  in  the  first  instance,  and 
the  pupil  is  dilated  with  atropin. 

Fracture  of  the  lower  jaw  is  generally  accompanied 
by  injury  to  the  tissues  of  the  mouth,  displacement  of  the 
teeth,  and  bleeding  from  the  mouth.  Where  the  injury 
is  severe,  it  is  often  necessary  to  wire  the  bone.  The  jaw 
is  supported  by  a  Barton  bandage  or  a  close-fitting  splint 
made  of  hard  rubber  or  poroplastic  felt  is  applied.  (See 
Splints.)  An  antiseptic  mouth-wash  must  be  constantly 
used.  Liquid  diet  is  necessary  for  about  six  weeks,  by 
which  time  union  has  usually  taken  place. 

Fractures  of  the  Pelvis. — A  fractured  pelvis  may  result 

41 


642        NURSING   IN   ACCIDENTS   AND   EMERGENCIES 

from  a  severe  fall  or  from  crushing  of  the  parts,  as  when  the 
patient  is  run  over  by  a  vehicle.  The  prominent  symptoms 
are  those  of  severe  shock  and  acute  local  pain;  the  patient 
is  unable  to  stand  or  to  sit.  Internal  hemorrhage  from 
injury  to  a  blood-vessel  or  rupture  of  one  of  the  pelvic 
organs  may  occur.  The  urine  should  be  kept  for  examina- 
tion; frequently  it  contains  blood  from  injury  to  the  genito- 
urinary organs. 

The  patient  is  placed  flat  on  his  back  on  a  mattress 
straightened  by  fracture-boards.  The  thighs  are  flexed 
by  pillows  placed  below  the  knees;  a  binder  or  wide  band- 
age is  secured  round  the  pelvis.  If  the  patient  is  rest- 
less, sand-bags  may  be  placed  on  either  side,  and  a  roller 
towel  be  passed  over  the  pelvis  and  under  either  sand-bag. 
Where  permissible,  pressure  on  the  coccyx  should  be 
guarded  against  by  the  use  of  a  rubber  ring  cushion,  very 
slightly  inflated.  Nothing  must  be  given  by  mouth  until 
the  extent  of  the  injuries  has  been  ascertained. 

The  chief  immediate  treatment  is  directed  toward  com- 
bating the  effects  of  shock  and  controlling  hemorrhage. 
Elevation  of  the  bottom  of  the  bed,  saline  hypodermoclysis, 
or  intravenous  infusion  are  the  usual  means.  A  bed- 
cradle  is  necessary  to  keep  the  weight  of  the  clothes  from  the 
pelvis;  at  the  same  time  care  must  be  taken  that  the  chest 
and  extremities  are  warmly  covered.  An  ice-bag  may  be 
suspended  from  the  cradle  over  the  lower  part  of  the  abdo- 
men. Stimulants  are  given  with  caution  on  account  of 
the  possible  hemorrhage.  Opium  is  generally  ordered  to 
relieve  the  pain  and  allay  restlessness. 

Fractures  of  the  pelvis  are,  in  the  majority  of  cases, 
fatal,  either  from  the  immediate  shock,  from  internal 
hemorrhage,  or  from  injury  to  one  of  the  pelvic  organs. 
Rupture  of  the  bladder  is  shown  by  the  extravasation 
of  urine  into  the  surrounding  tissue.  Where  the  condition 
of  the  patient  permits,  a  surgical  operation  is  performed 
and  the  bladder  repaired.  If  the  patient  lives  over  a  few 
days,  septic  peritonitis  or  perforation  is  a  common  com- 
plication. 

Such  cases  require  skilled  nursing.  Where  there  are 
evidences  of  internal  injuries  or  hemorrhage,  the  patient 


FRACTURES  643 

must  not  be  turned,  and  any  movement  must  be  the 
slightest  possible.  A  slipper  bed-pan  may  be  used;  if 
not  procurable,  the  motions  should  be  passed  on  pads  of 
tow.  Liquid  nourishment  is  given,  usually  in  small  quan- 
tities at  a  time.  For  excessive  thirst,  sips  of  boiling  hot 
water  or  hot  tea  are  preferable  to  cracked  ice.  Close 
watch  must  be  kept  for  such  symptoms  as  shivering, 
sudden  abdominal  pain,  distention,  rapid  rise  of  the  pulse, 
sudden  alterations  in  the  temperature,  and  syncope. 
Bed-sores  can  be  prevented  only  by  constant  vigilance  and 
cleanliness.  (See  Bed-sores.) 

Fracture  of  the  Spine. — A  fracture  of  the  spine  may  be 
due  to  direct  or  indirect  violence.  Commonly,  they  are 
simple  fractures,  but  as  the  result  of  a  violent  accident 
involving  crushing  or  tearing  of  the  soft  tissues  they  may 
be  compound.  They  are  invariably  complicated  by  some 
injury  to  the  spinal  cord.  Usually  dislocation  is  also 
present.  The  characteristic  feature  of  injuries  to  the 
spinal  cord  is  paralysis,  both  sensory  and  motor,  on  both 
sides  of  the  body  (paraplegia),  below  the  seat  of  injury, 
with  marked  hyperesthesia  above.  Control  of  the  sphinc- 
ter is  lost,  and  the  urine  and  bowel  movements  are  passed 
involuntarily.  In  severe  lesions  of  the  upper  cervical 
vertebra  death  occurs  instantaneously  from  paralysis  of 
the  respiratory  muscles  of  the  chest. 

The  gravity  of  the  condition  depends  on  the  extent  to 
which  the  spinal  cord  is  involved.  In  favorable  cases  the 
cord  remains  intact,  and  the  paralysis  is  due  to  the  pressure 
caused  by  the  extravasation  of  blood  and  serum.  There 
is  no  persistent  dislocation.  The  limbs  gradually  regain 
their  movements,  and  complete  recovery,  except  for  some 
local  stiffness  of  the  column,  usually  takes  place. 

In  the  majority  of  cases  the  injury  involves  twisting  or 
tearing  of  the  spinal  cord.  Partial  recovery  with  paraplegia 
may  take  place;  most  commonly  the  patient  dies,  either 
from  shock  during  the  first  twenty-four  hours,  or,  after 
lingering  weeks  or  months,  from  exhaustion  or  one  of  the 
complications  of  the  condition.  Common  complications 
are  cystitis,  bed-sores,  bronchitis,  and  hypostatic  pneu- 
monia. Compound  fractures  are  usually  quickly  fatal, 


644         NUltSING    IN    ACCIDENTS    AND    EMERGENCIES 

either  from  shock  or  hemorrhage,  or  later  from  septicemia 
or  meningitis. 

Where  it  can  be  procured,  the  patient  should  be  nursed  on 
a  water  or  an  air  mattress,  below  which  fracture-boards 
are  placed.  Scrupulous  care  is  necessary  to  prevent 
bed-sores,  as,  owing  to  the  paralysis  of  the  sphincters,  it 
is  difficult  to  keep  the  bed  clean  or  dry.  After  the  imme- 
diate symptoms  of  spinal  irritation  have  subsided,  per- 
mission is  generally  given  to  turn  the  patient  at  intervals, 
beginning  with  once  or  twice  a  day,  and  gradually  with 
greater  frequency.  Turning  not  only  removes  constant 
pressure,  but  also  lessens  the  risk  of  hypostatic  congestion 
of  the  lungs.  In  turning,  the  spine  must  be  kept  rigid  by 
careful  support  above  and  below  the  injury,  otherwise 
movement  may  at  first  cause  acute  local  pain,  and  in- 
crease the  injury  to  the  spinal  cord. 

The  bladder  is  emptied  at  regular  intervals  by  the 
catheter.  To  some  extent,  by  careful  management  in  the 
administration  of  laxatives  and  the  use  of  enemata,  the 
action  of  the  bowels  can  be  regulated  and  a  daily  evacuation 
at  a  regular  hour  effected.  If  cystitis  occurs,  the  bladder  is 
irrigated  daily.  Variations  of  the  pulse  and  temperature, 
attacks  of  acute  pain,  and  fits  of  mental  depression  or  excite- 
ment commonly  accompany  the  condition  in  its  progress. 

The  hygiene  should  be  as  good  as  can  be  obtained. 
The  diet  is  liquid  until  the  preliminary  symptoms  are 
passed;  later  it  should  be  varied  and  nourishing,  and  tonics 
are  usually  prescribed.  If  recovery  takes  place,  regular 
light  massage  and  passive  movements  may  be  ordered  to 
the  lower  extremities,  in  order  to  promote  nutrition  and 
prevent  rigidity  or  contraction. 

In  some  cases  an  attempt  is  made  to  relieve  the  pressure 
by  a  surgical  operation  involving  the  removal  of  a  portion 
of  the  vertebral  arch.  The  operation  is  known  as  laminec- 
torny.  In  other  cases  extension  apparatus  and  the  spinal 
jacket  are  used  to  overcome  the  local  dislocation. 

In  the  treatment  of  a  compound  fracture  the  wound  is 
dressed  daily  with  strict  aseptic  precautions,  and  every  care 
taken  to  keep  the  area  free  from  infection.  In  other 
respects  the  treatment  is  the  same  as  for  a  simple  fracture. 


DISLOCATION   OR   LUXATION 

DISLOCATION  OR  LUXATION 

A  dislocation  is  a  persistent  separation  of  the  articular 
surfaces  of  two  or  more  bones,  the  articulation  of  which 
constitutes  a  joint.  It  is  accompanied  by  a  wrenching 
of  the  tendons  and  ligaments,  and  frequently  by  injury 
to  the  adjacent  soft  tissues.  A  dislocation  in  which  the 
bones  are  immediately  replaced  is  called  a  sprain. 

Varieties. — Dislocation  may  be  complete  or  incomplete 
(subluxatiori) .  Like  a  fracture,  a  dislocation  is  said  to  be 
simple  or  closed,  when  unconnected  with  a  wound,  and 
compound  or  open,  when  combined  with  a  flesh  wound 
communicating  with  the  surface.  A  dislocation  is  des- 
cribed as  complicated  if,  together  with  the  dislocation,  a 
fracture  exists,  or  a  serious  injury  to  important  structures, 
as,  for  example,  a  dislocation  of  the  spinal  vertebrae,  in- 
volving pressure  on  the  spinal  column.  According  to  the 
position  of  the  displaced  bones,  a  dislocation  is  described 
as  forward,  backward,  or  to  either  side. 

The  symptoms  of  a  dislocation  are  deformity,  pain,  and 
rigidity;  voluntary  movement  is  either  restricted  or  lost; 
passive  movement  causes  severe  pain;  the  surrounding 
tissues  become  swollen  and  discolored.  A  dislocation  is 
distinguished  from  a  fracture  by  the  absence  of  crepitus 
or  abnormal  mobility. 

Dislocation  may  be  due  to  congenital  deformity,  or  the 
result  of  traumatism,  disease  of  the  bone,  or  violence, 
direct  or  indirect. 

The  reduction  of  a  dislocation  means  the  replacement  of 
the  bones  in  their  proper  position,  so  that  the  function  of 
the  member  is  not  impaired.  Manipulation,  traction, 
and  the  use  of  extension  or  counterextension  are  the  means 
employed.  When  reduced,  the  parts  are  kept  in  proper 
position  by  the  use  of  appropriate  splints  and  bandages. 
Those  used  in  the  treatment  of  a  fracture  near  a  joint  are 
usually  applicable  in  the  treatment  of  a  dislocation.  The 
part  is  kept  at  rest  until  the  wrenched  ligaments  or  other 
injury  to  the  soft  tissues  are  repaired,  after  which  passive 
movements  and  massage  are  usually  prescribed.  Gentle 
massage  without  passive  movement  is  often  prescribed 
earlv  in  the  treatment. 


646        NURSING   IN  ACCIDENTS   AND    EMERGENCIES 

If  not  properly  reduced,  a  dislocation  may  result  in 
permanent  deformity,  with  more  or  less  crippling.  In- 
expert assistants  should  be  careful  to  make  no  attempt  at 
reduction,  as  they  will  probably  only  increase  the  injury. 
Until  surgical  aid  can  be  procured,  the  limb  should  be 
supported  in  as  comfortable  a  position  as  possible,  and 
cold  compresses  or  an  ice-bag  applied  to  the  part,  in  order 
to  reduce  the  swelling  and  relieve  the  pain.  Hot  applica- 
tions may  be  preferred  if  the  pain  is  severe. 


Fig.  205. — Subcoracoid  dislocation  of  the  humerus  (Hoffa). 

While  a  fracture  can,  without  injury,  usually  wait  hours 
or  even  one  or  two  days  before  being  set,  a  dislocation 
requires  prompt  treatment.  If  not  seen  until  extensive 
swelling  has  occurred,  reduction  may  be  impossible.  By 
the  time  the  swelling  has  subsided,  a  growth  of  new  tissue 
has  taken  place  between  the  disarticulated  ends  of  the 
bones,  forming  what  is  known  as  a  fibrous  joint,  which  is 
useless  for  the  purpose  of  function. 

A  compound  dislocation  is  a  serious  condition.  If 
the  wound  becomes  infected,  ankylosis  of  the  joint  with 


DISLOCATION  OR   LUXATION  647 

permanent  crippling  will  probably  result.  The  wound 
from  the  moment  of  injury  must  be  treated  with  strict 
aseptic  precautions.  The  patient's  health  is  usually  built 
up  with  liberal  diet  and  tonics,  in  order  to  increase  his 
resistance  to  bacterial  invasion. 

Dislocation  of  the  lower  jaw  is  a  minor  ill  that  may 
frequently  be  reduced  without  much  difficulty.  The  jaw 
should  be  taken  between  the  two  hands,  the  operator  stand- 
ing directly  in  front  of  the  patient.  The  thumbs  are 


Fig.  206. — Dislocation  of  the  lower  jaw. 


placed  inside  the  mouth,  over  the  molar  teeth,  as  far  back 
as  possible.  Steady  pressure  is  then  made  downward  and 
backward  until  the  bone  slips  into  its  socket.  If.  any 
considerable  time  has  elapsed  between  the  occurrence  of 
the  dislocation  and  its  reduction,  a  small  blister  is  usually 
applied  immediately  over  the  joint  to  prevent  exudation. 
A  jaw  bandage  is  sometimes  applied  for  a  few  hours. 

Dislocation  of  a  finger  is  often  reduced  by  grasping  the 
hand  and  pulling  the  finger  firmly  and  in  a  straight  line 
from  the  hand.  A  finger  splint  should  then  be  applied 
and  a  cold  wet  dressing  to  keep  down  swelling. 

Sprain. — A  sprain  may  be  described  as  a  dislocation 
that  is  immediately  and  automatically  reduced.  The 
extent  of  injury  in  a  sprain  varies  greatly.  The  displace- 


648        NURSING    IN   ACCIDENTS   AND    EMERGENCIES 

ment  may  have  been  so  severe  as  to  cause  severe  wrenching 
or  tearing  of  the  ligaments  and  tendons.  In  these  cases 
there  are  severe  pain  and  much  local  swelling  and  discolora- 
tion, and  it  is  frequently  difficult  to  determine  whether 
the  condition  is  one  of  sprain  or  fracture. 

A  severe  sprain  should  be  kept  at  rest,  the  joint  elevated, 
and  either  hot  fomentations  or  cold  evaporating  compresses 
applied.  When  the  swelling  has  subsided,  a  splint  or 
plaster-of-Paris  bandage  is  applied  and  retained  for  one 
or  two  weeks,  after  which  massage  and  passive  movements 
are  generally  ordered,  and  the  joint  gradually  accustomed 
to  use. 

For  slighter  injuries  a  wet  bandage  is  generally  applied, 
and  over  it  a  compress  of  evaporating  lotion,  which  is 
constantly  renewed.  After  six  to  twelve  hours  massage 
and  passive  movements  are  given,  and  the  bandage  and 
compresses  reapplied.  In  the  case  of  sprained  ankle, 
gentle  exercise,  helped  with  a  walking-stick,  is  generally 
advised  as  soon  as  possible  in  spite  of  pain.  Instead  of 
the  cold  compresses,  hot  fomentations  may  be  used  or  the 
joint  may  be  douched  alternately  with  very  hot  and  very 
cold  water. 

Another  method  of  treatment,  especially  in  sprains  of 
the  ankle,  if  it  can  be  applied  immediately,  is  to  strap  the 
joint  (Chap.  VIII).  In  this  case  the  patient  is  generally 
encouraged  to  exercise  the  joint  in  moderation. 

WOUNDS 

A  wound  or  trauma  is  described  as  a  "  solution  in  the 
continuity  of  the  soft  tissues  "  caused  by  violence.  Though 
impaired,  the  tissues  are  not  destroyed,  as  in  the  case  of 
burns. 

According  to  the  character  of  the  injury,  they  are  classed 
as  incised,  lacerated,  contused,  or  punctured. 

An  incised  wound  is  inflicted  by  a  sharp  cutting  instru- 
ment. The  tissues  are  sharply  divided.  Hemorrhage  is 
commonly  present.  If  a  wound  is  deep,  important  struc- 
tures, such  as  tendons,  large  blood-vessels,  or  an  entire 
muscle  mav  be  divided. 


WOUNDS  049 

A  lacerated  wound  is  one  in  which  the  tissues  are  torn 
apart.  Usually  there  is  not  much  hemorrhage,  as  torn 
arteries  tend  to  contract,  and  the  surfaces  thus  roughened 
favor  the  formation  of  blood-clots.  The  surrounding 
tissues  are  generally  bruised.  Lacerated  wounds  are 
common  in  accidents  caused  by  machinery.  An  animal 
in  biting  also  inflicts  a  lacerated  wound. 

A  contusion  is  a  bruise.  Contused  wounds  may  com- 
prise a  slight  bruising  or  complete  crushing  of  the  parts. 
They  are  inflicted  by  direct  violence,  such  as  a  blow  from 
a  blunt  instrument  or  a  severe  beating. 

In  a  punctured  wound  the  tissues  are  pierced  by  a  pointed 
narrow  instrument,  frequently  a  sharp-pointed  nail  or 
splinter  of  wood.  They  are  also  caused  by  a  gunshot. 
The  instrument  inflicting  the  wound  is  frequently  left, 
whole  or  in  part,  in  the  wound.  There  is  little  hemorrhage, 
and  the  immediate  injury  to  the  tissues  is  often  slight. 
Punctured  wounds  are  peculiarly  liable  to  certain  bacterial 
infections,  especially  infection  by  the  tetanus  bacillus. 

Healing  of  Wounds. — Where  the  tissues  have  been  di- 
vided, the  wound  is  closed  or  healed  by  the  formation  of 
fresh  tissue,  which  grows  from  the  cells  of  the  underlying 
connective  tissue.  The  tissue  so  formed  is  spoken  of  as 
scar  tissue.  On  the  surface  of  the  body,  when  fully 
formed,  it  is  at  first  pinkish,  and  finally  has  a  white,  shiny 
appearance.  Scar  tissue  is  inelastic,  and  has  neither  hair- 
follicles  nor  secretory  glands.  In  the  young  only  it  may 
become  to  a  certain  extent  covered  with  true  skin. 

Where  the  divided  surfaces  of  a  wound  can  be  brought 
together  and  kept  in  close  apposition,  little  new  tissue  is 
necessary,  and  healing  takes  place  very  quickly.  Healing 
is  then  said  to  take  place  by  first  intention,  or,  in  other  words, 
primary  union  results.  In  primary  union  there  is  no  inflam- 
mation, the  surfaces  of  the  wound  appear  to  become  glued 
together.  Where  the  edges  of  a  wound  are  finely  adjusted, 
scarring  is  very  slight. 

When  there  is  destruction  as  well  as  separation  of  the 
tissues,  primary  union  is  not  always  possible.  The 
wound  then  heals  by  a  process  known  as  granulation. 
Healing  is  then  said  to  be  by  secondary  union. 


G50        NURSING   IN   ACCIDENTS   AND    EMERGENCIES 

A  granulation  is  a  minute  process  or  new  cell  developed 
from  a  connective-tissue  cell.  Starting  from  the  sides  and 
bottom  of  a  wound,  the  granulations  grow  slowly  until 
the  cavity  of  the  wound  is  completely  filled  and  level  with 
the  surface. 

A  healthy  granulation  looks  like  a  minute  bright-red 
speck.  Unhealthy  or  indolent  granulations  look  pale  and 
flabby.  They  are  then  stimulated  by  such  applications  as 
balsam  of  Peru,  borine,  oxid  of  zinc,  or  a  weak  solution  of 
nitrate  of  silver. 

In  some  wounds  granulations  grow  too  rapidly,  forming 
an  uneven  surface;  they  may  be  burnt  away  or  reduced  by 
applications  of  nitrate  of  silver  stick  or  of  blue  stone  (sul- 
phate of  copper).  Too  free  granulation  is  described  as 
redundant. 

When  extensive  surfaces  heal  by  granulation,  the  in- 
elastic scar  tissue  is  apt  to  cause  contraction  of  the  parts. 
If  the  wound  is  near  a  joint,  permanent  crippling  may 
result.  The  condition  is  guarded  against  in  the  treatment 
by  the  application  of  suitable  splints  or  extension,  and  the 
early  practice  of  passive  movements.  A  deep  wound 
may  show  a  tendency  to  close  at  the  top  before  healing 
is  complete.  The  mouth  has  then  to  be  kept  open  by  a 
drainage-tube  or  a  strip  of  gauze,  etc. 

In  flat  superficial  wounds  healing  takes  place  first  from 
the  margins  and  later  from  isolated  spots  over  the  surface  of 
the  wound.  The  granulation  presents  the  appearance  first 
of  a  red  line,  with,  as  healing  progresses,  an  outer  blue  line 
forming  a  ring  inclosing  the  wound.  The  ring  gradually 
advances  toward  the  center,  leaving  behind  the  freshly 
grown  scar  tissue.  The  healing  of  large  superficial  wounds 
is  frequently  hastened  by  the  process  of  skin-grafting. 

TREATMENT  OF  ACCIDENTAL  WOUNDS 
The  treatment  of  all  such  wounds  comprises:  (1)  The 
arrest  of  any  hemorrhage;  (2)  the  perfect  cleansing  of  the 
part  and  adjacent  tissues,  including  the  removal  of  all 
foreign  matter;  (3)  the  placing  of  the  part  at  rest;  (4)  the 
repair  of  the  tissues. 

The  possibility  of  shock  must  not  be  overlooked,  and  the 


WOUNDS  Gol 

patient,  as  a  matter  of  routine,  should  be  spared  unneces- 
sary standing  or  sitting  upright  or  exposure  to  cold,  such 
as  waiting  in  a  draughty  hall.  For  the  same  reason  wounds 
should  be  treated  promptly.  A  point  to  be  emphasized 
is  that  the  tissues  must  be  gently  handled  to  avoid  further 
bruising.  Not  only  will  the  process  of  repair  be  prolonged, 
but  bruised  tissues  are  considered  to  present  reduced 
resistance  to  bacterial  invasion. 

Hemorrhage  is  arrested  by  one  or  other  of  the  methods 
already  described.  Where  possible,  the  bleeding  vessels 
are  tied. 

The  thorough  cleansing  of  a  wound  is  probably  the  most 
important  factor  in  recovery,  whether  the  wound  is 
small  or  great.  The  adjacent  parts  should  be  scrubbed 
with  hot  soap  and  water  and  covered  with  a  sterile  towel 
wrung  out  in  an  antiseptic  solution. 

The  wound  is  then  gently  and  thoroughly  washed,  if 
free  from  foreign  matter,  with  an  antiseptic  solution  or 
sterile  water;  if  dirty,  with  soap  and  water,  followed  by 
plentiful  irrigation  with  an  antiseptic  solution.  Every  par- 
ticle of  foreign  matter  must  be  picked  away  before  a  wound 
is  closed,  often  a  tedious  process.  If  the  pain  is  severe  or 
the  process  protracted,  it  is  sometimes  necessary  to  place 
the  patient  under  an  anesthetic. 

As  soon  as  a  wound  is  cleansed  it  is  protected  by  a 
sterile  dressing. 

Accidental  wounds  are  rarely  clean  and  frequently 
complicated  by  bruising,  laceration,  or  extensive  inflam- 
mation. In  this  condition  the  dressing  usually  takes  the 
form  of  an  antiseptic  compress,  changed  at  regular  inter- 
vals or  kept  moist  by  some  device.  An  ordinary  method  is 
as  follows:  The  wound  is  covered  with  several  pieces  of 
gauze,  wet  with  the  antiseptic  preferred,  and  kept  in  place 
by  a  light  bandage.  The  member  is  laid  on  a  pillow  cov- 
ered with  a  piece  of  rubber  sheeting.  A  douche  can  filled 
with  the  antiseptic  solution,  to  which  is  attached  a  length 
of  rubber  tubing  terminating  in  a  glass  pipet,  is  hung 
above  the  bed  at  a  convenient  point,  so  that  the  pipet 
drips  directly  on  to  the  dressing.  By  this  method  the 
frequent  changing  of  the  compress  is  avoided. 


652        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 

REPAIR  OF  THE  WOUND 

In  an  incised  wound  surfaces  are  brought  together  and 
kept  in  apposition  usually  by  sutures,  or  in  minor 
injuries  by  strips  of  adhesive  plaster.  In  choosing  the 
needle,  where  stitches  are  to  be  introduced  deep  into  the 
tissues,  as  in  large  fleshy  wounds,  a  needle  in  which  part 
of  the  blade  is  sharp  is  often  preferred.  It  passes  quickly 
and  inflicts  less  pain.  Where  the  tissues  are  delicate  and 
easily  torn,  as  in  wounds  of  the  face  or  mucous  membrane, 
such  needles  inflict  injury,  and  one  rounded  like  the  ordi- 
nary sewing  needle  is  used.  Care  must  be  taken  that  the 
needles  are  sharp  or  much  pain  is  caused.  The  sutures 
must  be  a  convenient  length  to  tie  in  a  surgical  knot  after 
they  are  in  place.  They  must  be  tied  sufficiently  tight  to 
keep  the  edges  of  the  wound  in  apposition,  but  not  so 
tight  as  to  pucker  the  wound. 

Before  putting  in  the  stitches  the  edges  of  the  wound 
must  be  nicely  adjusted  or  unsightly  scarring  will  result. 
The  stitches  themselves  cause  scarring,  and  are,  therefore, 
not  left  in  place  longer  than  necessary.  Superficial 
stitches  about  the  face  of  the  wound,  thoroughly  clean  and 
kept  strictly  sterile,  may  often  be  removed  as  early  as  the 
fourth  day.  For  deep  wounds  nine  days  are  usually  allowed 
to  elapse.  If  sutures  are  removed  too  soon,  the  edges  may 
gape  and  primary  union  fail  to  take  place.  If  there  is  much 
local  inflammation,  the  tissues  between  the  stitches  become 
swollen  and  tense.  To  relieve  the  tension,  one  or  more  of 
the  stitches  may  be  removed.  Local  inflammation  may 
frequently  be  the  result  of  rough  handling  of  the  tissues  or 
of  imperfect  cleansing.  It  is  often  the  first  sign  of  infec- 
tion of  a  wound. 

To  remove  a  stitch,  a  pair  of  sharp-pointed  scissors 
and  a  pair  of  forceps  are  used.  The  stitch  is  divided 
close  to  the  tissue.  The  long  end  with  the  knot  is  then 
seized  with  the  forceps  and  gently  and  quickly  pulled, 
following  the  direction  of  the  curve  made  by  the  stitch. 
If  the  scar  does  not  appear  perfectly  strong,  strips  of 
plaster  should  replace  the  suture  for  a  few  days. 

Strips  of  plaster  should  be  cut  narrow  and  cross  the 


KEI'AIR   OF   THE    WOUND  653 

wound  from  either  side,  keeping  a  space  between  each 
pair,  so  that  the  incision  is  not  entirely  covered.  Before 
applying,  the  edges  of  the  wound  should  be  held  together 
by  gentle  pressure  of  the  tissues  on  either  side  toward  the 
wound. 

If  a  wound  is  perfectly  clean  and  the  tissues  are  not 
bruised,  the  closing  is  complete.  In  the  contrary  condition 
some  inflammation  will  take  place  and  discharge  will 
form,  which  must  be  allowed  to  escape.  The  discharge 
may  be  an  exudation  of  blood  or  serum,  or,  if  the  wound 
is  infected,  may  contain  pus.  To  provide  for  such  dis- 
charge an  opening  is  left  at  the  lower  end  of  a  wound  in 
which  is  inserted  a  drain,  which  may  consist  of  a  straight 
piece  of  sterile  gauze,  a  few  strands  of  silk  or  horsehair, 
or  similar  substances,  or  a  short  length  of  rubber  tubing. 
The  drain  at  first  should  reach  to  the  bottom  of  the 
wound  and  be  gradually  shortened  as  healing  takes  place. 
When  the  discharge  subsides,  it  is  removed  altogether. 

Sutured  wounds  are  protected  by  a  sterile  dressing,  and 
usually  do  not  require  dressing  until  the  stitches  are  re- 
moved. If  drainage  has  been  necessary,  they  are  dressed 
more  frequently — daily  or  every  second  day  for  fresh  wounds 
and  usually  at  longer  intervals  for  chronic  varieties. 

The  temperature  chart  is  a  guide  for  the  necessity  of 
dressing.  A  rise  of  temperature,  especially  if  preceded 
by  shivering  or  chilly  sensations,  frequently  indicates 
local  inflammation  or  the  formation  of  pus.  The  wound 
is  then  examined  and  redressed. 

In  both  incised  and  in  lacerated  wounds  the  possibility 
of  separation  of  the  tendons  must  be  remembered  before 
the  wound  is  closed.  This  is  particularly  liable  to  happen 
in  injuries  to  the  wrist  or  hand.  The  condition  is  demon- 
strated by  inability  to  move  the  wrist  or  the  fingers.  If 
the  ends  of  a  divided  tendon  are  exposed,  they  should 
be  seized  at  once  by  whoever  is  first  present,  and  trans- 
fixed by  a  needle  or  piece  of  sterile  silk.  Owing  to  the 
muscular  contraction,  they  become  readily  withdrawn  into 
the  tissues  and  are  often  extremely  difficult  to  find  later. 
When  several  tendons  are  divided,  it  is  obviously  imperative 


654       NURSING   IN  ACCIDENTS  AND  EiMERGENCIES 

that  the  right  ends  should  be  sewn  together.  The  opera- 
tion is  generally  long  and  tedious. 

A  lacerated  wound  is  treated  in  the  same  way  as  an 
incised  wound,  whenever  possible.  Provided  the  wound 
has  been  perfectly  cleansed  and  kept  strictly  sterile,  and 
that  the  surrounding  tissues  are  not  greatly  bruised,  the 
results  are  often  extremely  good.  Wet  dressings  are  usu- 
ally preferred.  Where  the  laceration  is  extensive  and  the 
local  bruising  severe,  the  wound  is  left  altogether  open 
or  only  partially  closed,  allowing  for  drainage.  In  many 
cases  sloughing  takes  place,  or  the  wound  becomes  in- 
fected, usually  from  foreign  matter  at  the  time  of  injury. 
In  such  conditions  the  wound  is  frequently  treated  by 
constant  irrigation,  or  the  part  is  immersed  in  a  local  anti- 
septic bath  (Chap.  II). 

In  a  contused  wound  the  treatment  depends  on  the 
extent  of  injury.  If  the  bruising  is  slight,  cold  com- 
presses may  be  used ;  if  extensive,  hot  antiseptic  compresses 
are  preferred,  as  heat,  by  bringing  a  large  supply  of  blood 
to  the  part,  tends  to  restore  vitality  and  promotes  the 
absorption  of  inflammatory  products.  Contused  wounds 
also  are  very  liable  to  infection.  When  the  injury  is  ex- 
tensive, they  may  be  followed  by  sloughing  or  even,  in 
severe  cases,  by  gangrene. 

The  treatment  of  a  punctured  wound  is  guided  by  the 
history  of  the  injury.  In  all  cases  search  should  be  made 
for  fragments  of  the  instrument  that  has  inflicted  the 
wound.  If  there  is  a  possibility  of  dirt  having  been  intro- 
duced into  the  wound  at  the  time  of  the  injury,  as  from  the 
soil,  the  clothing,  or  even  the  skin  of  the  patient,  the  treat- 
ment usually  is  to  convert  the  punctured  wound  into  an 
open  one,  thoroughly  cleanse  the  part  with  an  antiseptic, 
and  provide  for  drainage. 

The  reason  for  this  should  be  understood.  The  com- 
plication most  to  be  dreaded  in  the  healing  of  wounds  is 
tetanus.  The  tetanus  germ,  we  remember,  is  anaerobic, 
that  is  to  say,  develops  in  the  absence  of  air.  The  recesses 
of  a  punctured  wound  of  which  the  opening  is  sealed  by  a 
sterile  dressing  forms  an  ideal  medium  for  its  cultivation. 
The  danger  of  its  development  is  lessened  if  the  wound  is 


REPAIR   OF   THE    WOUND  655 

freely  exposed.  The  tetanus  germ  has  been  known  to 
develop  in  a  punctured  wound  so  small  and  apparently 
so  unimportant  as  that  caused  by  a  hat-pin  driven  into 
the  scalp  in  a  fall  on  the  head. 

Even  where  the  wound  is  clean,  a  wet  dressing  is  usually 
preferred  to  a  dry  one,  as  helping  to  dislodge  minute 
particles  of  foreign  matter  that  may  have  been  overlooked. 

A  gunshot  wound  has  frequently  the  characteristics 
of  both  a  lacerated  and  contused  wound.  In  a  penetrating 
gunshot  wound  vital  organs  may  be  injured  and  important 
structures  badly  torn.  Small  gunshot  wounds,  such  as 
those  inflicted  by  toy  pistols  or  fireworks,  are  liable  to 
be  followed  by  tetanus  from  the  lodgment  of  pieces  of  soiled 
rags,  etc.,  in  the  wound.  They  are  generally  laid  open, 
cleansed,  and  dressed  with  a  wet  antiseptic  dressing.  The 
administration  of  tetanus  antitoxin  serum  is  generally 
advised. 

COMPLICATIONS    OF   WOUNDS 

The  healing  of  wounds  may  be  complicated  by  inflam- 
mation, local  infection,  the  formation  of  abscesses,  sloughs, 
gangrene,  or  emboli;  and  by  special  infections,  of  which 
the  most  important  are  erysipelas,  general  septicemia, 
tetanus,  and  scarlet  fever.  A  condition  developing  from 
a  wound  is  described  as  traumatic. 

Inflammation. — Except  in  the  case  of  clean,  incised 
wounds,  wounds  caused  by  accident  are  almost  invariably 
followed  by  a  certain  amount  of  inflammation.  The 
phenomenon  of  inflammation,  its  symptoms  and  treatment, 
are  described  in  Chapter  III.  Inflammation  in  wounded 
tissue  is  treated  on  the  same  general  principles,  i.  e.,  rest 
to  the  part,  and,  unless  the  inflammation  is  slight,  the 
local  application  of  heat  or  cold,  in  the  form  of  stupes  or 
compresses,  constant  local  irrigation,  or  the  local  anti- 
septic bath.  In  wounds  of  the  extremities  the  part  is 
kept  more  especially  at  rest  by  the  application  of  suitable 
splints. 

Inflamed  tissues  offer  very  reduced  resistance  to  bacterial 
invasion;  antiseptics,  for  this  reason,  are  generally  used  in 
the  dressing  and  treatment  of  accidental  wounds,  although 


656        NURSING   IN   ACCIDENTS  AND   EMERGENCIES 

the  tendency  of  modern  aseptic  technic  is  to  discard  their 
use  as  far  as  possible. 

Infection. — In  spite  of  strict  technic  and  careful 
cleansing,  local  infection  by  one  of  the  pus-producing 
germs,  commonly  the  staphylococcus  pyogenes  aureus  (p. 
439) ,  is  a  common  complication  in  the  healing  of  wounds 
of  accidental  origin.  The  most  prominent  general  symp- 
toms are  shivering,  rise  of  temperature,  and  malaise; 
locally  there  are  inflammation,  tension,  and  the  formation 
of  pus.  The  local  treatment  lies  in  the  use  of  antiseptics 
and  the  encouragement  of  drainage;  the  hot  antiseptic 
compress  is  a  common  form  of  treatment  combined 
with  regular  irrigation  with  an  antiseptic  solution.  Heat 
favoring  suppuration  may,  however,  be  contraindicated 
in  some  conditions.  If  pus  forms,  the  wound  is  opened  up, 
the  abscess  cavity  evacuated,  and  some  form  of  drain  in- 
troduced. Until  the  symptoms  of  acute  infection  have 
subsided,  the  wound  is  usually  dressed  at  frequent  intervals. 

It  must  always  be  remembered  that  an  infected  wound 
may  infect  others.  Strict  technic  must  be  observed  in 
changing  the  dressings.  The  dressing  should  be  reserved 
scrupulously  to  the  last,  and  no  other  wound  should 
be  exposed  during  the  dressing  of  an  infected  one.  Where- 
ever  practical,  infected  wounds  are  not  nursed  in  the  same 
ward  as  clean  operation  cases. 

The  most  virulent  form  of  local  infection  is  by  the 
bacillus  pyocyaneus,  a  pus-producing  germ  belonging  to 
the  bacillus  group  (p.  392).  The  discharge  has  a  blue- 
green  or  blue  color,  and  is  commonly  known  as  blue  pus. 
The  condition  is  highly  infectious.  Wounds  with  this 
complication  are  usually  isolated  from  the  general  surgical 
wards,  and  those  concerned  in  dressing  the  wound  or  in 
nursing  the  patient  are  forbidden  to  enter  the  operating- 
rooms  or  "  clean "  wards.  Blue-pus  infection  is  not 
infrequently  followed  by  general  septicemia.  The  treat- 
ment is  the  same  as  in  other  local  infections,  but  special 
attention  is  given  to  building  up  the  patient's  strength  by 
generous  diet,  good  hygiene,  and,  usually,  the  use  of  a 
stimulant. 

Inflammation  spreading  to  the  adjacent  cellular  tissue 


REPAIR    OF   THK    \VoHNI)  657 

is  known  as  cellulitis,  and,  in  severe  cases,  closely  resembles 
erysipelas.  The  onset  is  usually  less  abrupt,  the  redness 
not  so  acutely  defined,  and  the  physical  symptoms  much 
less  severe.  Except  as  complicated  by  infectious  processes, 
simple  cellulitis  is  not  considered  contagious.  The  usual 
treatment  for  inflamed  conditions  is  followed;  if  the  tissues 
are  infiltrated  with  infectious  processes,  free  incision  is 
usually  performed,  and  drainage  established;  but  the  treat- 
ment is  obviously  guided  by  the  structures  involved. 

Slough. — A  slough  is  a  piece  of  dead  tissue  in  living 
tissue;  in  other  words,  a  strictly  localized  gangrene.  The 
word  is  used  in  connection  only  with  soft  tissues.  A  dead 
piece  of  bony  tissue  is  called  a  sequestrum.  Sloughs  occur 
when,  for  some  reason,  there  is  not  sufficient  blood-supply 
to  enable  the  wounded  tissue  to  recover  its  vitality.  The 
blood-supply  may  be  cut  off  by  the  severing  of  important 
vessels,  by  the  extensive  crushing  of  the  tissues,  or  by  the 
prolonged  application  of  cold  to  a  large  contused  area. 
Lacerated  or  contused  wounds  and  burns  are  most  prone 
to  the  formation  of  sloughs.  When  a  slough  has  formed,  it 
is  not  reabsorbed,  but  must  be  thrown  off.  Nature 
accomplishes  this  by  a  local  acute  inflammation  between 
the  living  and  the  dead  tissue.  The  process  is  helped  by 
hot  fomentations,  but  as  they  tend  to  increase  inflamma- 
tion and  favor  suppuration,  they  are  not  always  considered 
advisable. 

Sloughs  should  not  be  pulled  away,  or  hemorrhage  may 
result.  Portions  already  separated  are  generally  carefully 
cut  away  from  the  remaining  parts.  On  separating,  a 
slough  leaves  an  exposed  surface,  which  heals  by  granula- 
tion. If  the  cavity  is  deep,  it  is  usually  packed  with 
gauze,  generally  saturated  with  an  antiseptic  or  a  stimulant 
preparation.  The  wound  is  dressed  daily,  and  thoroughly 
irrigated  with  an  antiseptic  solution.  Another  method  is 
to  dust  the  cavity  with  a  sterile  antiseptic  powder  and 
pack  it  with  dry  gauze.  The  granulations  are  apt  to  be 
indolent.  The  local  suppuration  has  a  tendency  to  spread 
along  the  connective  tissue,  causing  the  small  accumula- 
tions of  pus  known  as  pockets,  and  the  formation  of  small 
sinuses.  A  sinus  is  a  passage  leading  from  the  skin  surface 
4-2 


658        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 

to  a  pus-cavity.  A  similar  passage  opening  on  a  mucous 
membrane  is  called  &  fistula. 

Gangrene,  the  total  death  of  a  part,  involves  both  soft 
and  bony  tissues  and  occurs  most  usually  in  the  lower  ex- 
tremities. It  is  most  commonly  associated  with  condi- 
tions in  which  the  blood-supply  is  deficient,  especially 
diabetes  and  senility,  when  a  small  injury  may  be  followed 
by  gangrene.  In  wounds  it  is  caused  locally  by  the  cutting 
off  of  the  blood-supply,  as  by — (1)  the  division  of  a  large 
blood-vessel,  such  as  the  femoral  artery;  (2)  strangulation, 
accidental,  or  from  prolonged  application  of  a  tourniquet; 
(3)  embolism,  the  blocking  of  a  vessel  by  a  blood-clot. 

Gangrene  may  be  dry  or  moist.  When  the  immediate 
result  of  a  wound,  it  is  distinguished  as  traumatic  gangrene. 
A  black  local  discoloration  is  first  noticed,  which  spreads 
slowly  or  rapidly,  according  to  the  physical  condition. 
As  decomposition  progresses  the  odor  is  very  offensive. 
In  time  a  line  of  demarcation  forms,  as  in  the  separation 
of  sloughs,  and  the  part  is  thrown  off,  leaving  a  discharging 
unhealthy  surface.  In  the  aged  or  feeble  death  frequently 
takes  place  before  separation  occurs. 

The  question  of  operation  is  decided  by  many  conditions. 
Unless  the  gangrene  shows  signs  of  spreading  very  rapidly, 
it  is  not  usual  to  amputate  until  the  line  of  demarcation  has 
formed — a  process  often  requiring  many  months. 

In  the  local  treatment  the  extremity  is  elevated  and 
wrapped  closely  in  many  layers  of  warm  absorbent  cotton. 
If  the  gangrene  is  dry,  the  dressings  are  usually  kept  dry, 
and  the  part  dusted  with  an  antiseptic  powder.  In  moist 
gangrene  applications  of  warm  or  hot  antiseptic  compresses 
are  frequently  used  (boric,  2  per  cent.,  or  bichlorid,  1  : 
5000),  and  changed  every  four  or  six  hours.  In  dressing, 
care  must  be  taken  that  the  surface  is  not  chilled  by  ex- 
posure to  cold  air.  The  limb  above  the  part  is  kept  also 
closely  wrapped,  and  should  receive  regular  rubbing  in 
order  to  promote  a  good  circulation. 

The  general  treatment  is  directed  toward  supporting  the 
health  with  a  nourishing  diet  and  good  hygiene.  The  skin 
requires  special  care,  as  bed-sores  form  easily.  Tonics  and 
alcoholic  stimulants  are  generally  prescribed.  Heavy  pa- 
tients are  nursed  most  comfortably  on  an  air-  or  water-bed. 


REPAIR   OF   THE    WOUND  659 

Embolism  is  the  blocking  of  a  blood-vessel  by  a  clot  of 
blood.  A  clot  that  is  set  free  in  the  circulation  and  finally 
lodges  in  a  vessel  is  called  an  embolus;  a  clot  remaining 
where  it  forms,  and  causing  plugging  of  the  vessel,  is  called  a 
thrombus,  and  the  condition  is  known  as  thrombosis.  Nor- 
mal blood  does  not  clot  in  an  unimpaired  vessel.  If,  how- 
ever, the  walls  of  a  vessel,  or  of  the  lining  of  the  valves 
of  the  heart,  are  roughened  by  inflammation  or  injury,  fib- 
rin tends  to  become  deposited,  and  a  clot  is  formed,  which 
is  readily  swept  into  the  blood-stream.  Thrombosis  is  the 
result  of  a  diseased  or  inflamed  condition  of  a  blood-vessel 
or  of  a  valve  of  the  heart.  Common  causes  are  phlebitis, 
arterial  degeneration,  infection,  endocarditis,  and  aneu- 
rysm.  The  symptoms  develop  gradually,  and  are  modified 
by  the  locality  in  which  the  thrombosis  occurs. 

Thrombosis  of  a  vessel  in  an  extremity  is  accompanied 
by  local  swelling,  with  tenderness  along  the  line  of  the 
vessel.  Some  physical  disturbance  is  also  present.  An 
embolus  is  caused  by — (1)  Separation  of  a  thrombus;  (2) 
laceration  of  vessels,  as  by  a  fracture  or  other  injuries;  (3) 
use  of  styptics  in  the  treatment  of  hemorrhage  from  large 
vessels,  for  example,  the  uterine  sinuses. 

An  embolus  travels  along  the  circulation  until  it  arrives 
at  a  blood-vessel  not  large  enough  to  allow  of  its  passage. 
Lodging  in  a  cerebral  vessel,  in  one  of  the  large  vessels 
leading  to  or  from  the  lungs,  or  in  the  heart  itself,  grave 
physical  symptoms  develop  abruptly. 

In  cerebral  embolism  the  symptoms  are  those  of  apo- 
plexy, and  are  more  or  less  severe,  according  to  the  vessel 
affected.  There  may  be  hemiplegia  or  general  paralysis. 
Recovery  is  rare.  In  pulmonary  embolism  the  prominent 
symptoms  are  sudden  dyspnea,  cyanosis,  and  loss  of 
consciousness.  Death  follows  quickly  in  a  few  hours  at 
most.  In  cardiac  embolism  the  symptoms  are  the  same, 
but  death  occurs  almost  instantaneously  from  arrest  of 
the  function  of  the  heart. 

Traumatic  embolism  is  not  a  common  complication  in 
the  healing  of  wounds. 

Keloid. — A  keloid  is  a  tumor  occurring  on  the  surface  of 
a  scar  after  healing  is  complete,  due  to  an  overactivity 


NURSING   IN   ACCIDENTS   AND   EMERGENCIES 

of  the  connective  tissue.  It  is  usually  removed  by  opera- 
tion, but  frequently  recurs.  The  colored  races  are  more 
prone  to  keloid  than  the  white. 

GENERAL  INFECTIONS  DEVELOPING  FROM  WOUNDS 

General  septicemia  following  accidental  wounds,  the 
result  of  the  absorption  of  septic  processes  into  the  general 
system,  is  in  no  respect  different  from  the  same  condition 
following  an  operation,  the  symptoms  and  treatment  of 
which  have  been  already  described. 

Erysipelas  is  an  infection  due  to  a  micro-organism  of  the 
streptococcus  variety,  which  invades  the  system  only 
through  an  abrasion  of  the  skin  or  mucous  membrane. 
The  prominent  characteristic  of  erysipelas  is  a  crimson 
rash,  with  well-defined  edges,  occurring  in  the  vicinity 
of  a  wound,  accompanied  by  swelling  and  induration  of 
the  tissues  (p.  730).  The  temperature  rises  abruptly,  often 
to  104°  F.  or  over;  the  patient  shows  the  usual  physical 
accompaniments  of  fever  (p.  722),  and  is  generally  delir- 
ious. The  rash  fades  after  four  or  five  days,  and  is  followed 
by  desquamation.  If  there  are  no  local  conditions  to  keep 
the  temperature  up,  it  usually  falls  about  the  end  of  a 
week,  and  frequently  by  crisis,  after  which  convalescence 
is  rapid. 

As  the  organism  is  introduced  through  the  abraded 
surface,  a  case  of  erysipelas  is  a  menace  to  any  wound  with 
which  it  may  be  in  direct  or  indirect  contact  (through 
nurses,  dressers,  etc.).  (See  Chap.  XIV).  An  erysipelas 
case  is  usually  strictly  isolated  from  other  surgical  cases 

The  treatment  comprises  a  liberal  liquid  diet,  and,  as 
in  all  conditions  of  general  sepsis,  stimulants — whisky  or 
brandy — are  given  in  considerable  quantities;  usually 
some  form  of  iron  is  also  prescribed,  and  the  system  is 
thoroughly  purged. 

Local  treatment  consists  in  keeping  the  affected  area 
covered,  and  such  applications  as  ichthyol  ointment, 
carbolic  ointment,  tincture  of  iodin,  etc. 

True  erysipelas  is  a  comparatively  rare  complication 
in  the  healing  of  wounds.  The  so-called  idiopathic  variety 
occurs  on  the  face,  usually  beginning  at  the  nose  and 


REPAIR   OF   THE   WOUND  661 

spreading  to  the  hair-line.  Although  known  as  idio- 
pathic  or  spontaneous  (in  contradistinction  to  traumatic), 
it  is  considered  that  the  germ  usually  gains  entrance 
through  some  small  abrasion,  probably  on  the  mucous  mem- 
brane of  the  nose.  Burns,  where  the  surface  is  extensively 
denuded,  are  particularly  liable  to  erysipelas  infection. 

Scarlet  Fever. — Traumatic  scarlet  fever  is  not  in  any 
respect  different  from  the  idiopathic  variety.  The  attack 
is  generally  a  mild  one,  but  is  capable  of  infecting  a  third 
person  with  a  severer  form.  It  is  often  impossible  to  trace 
the  origin  of  the  infection.  Patients  freshly  operated  on 
and  women  during  the  puerperium  are  specially  liable  to 
scarlet  fever  infection.  A  nurse  who  has  been  in  contact 
with  scarlet  fever  even  indirectly  should  not  undertake 
either  an  operation  case  or  a  maternity  case  without  first 
notifying  the  surgeon  of  the  fact.  The  usual  precautions 
for  isolation  must  be  observed. 

Tetanus. — The  tetanus  germ  is  introduced  by  direct 
inoculation,  usually  at  the  time  of  an  injury.  Wounds 
contaminated  by  soil  are  especially  liable  to  be  infected 
(p.  442).  The  symptoms  may  develop  shortly  after  an 
operation  or  not  for  a  week  or  more.  One  of  the  early 
symptoms  is  a  stiffness  about  the  jaws,  the  first  sign  of 
which  must  be  promptly  reported.  The  chief  symptoms 
of  tetanus  are  the  characteristic  convulsions  (p.  683), 
accompanied  by  irregular  fever  and  great  prostration. 

The  present  treatment  is  to  give  tetanus  antitoxin 
serum  at  as  early  a  period  as  possible;  the  wound  is  freely 
opened,  as  described  above.  The  patient  is  isolated,  and 
the  room  kept  as  absolutely  quiet  as  possible,  since  the 
slightest  noise  brings  on  a  convulsion.  A  liberal  diet  is 
necessary;  if  the  jaw  is  locked,  the  patient  is  usually  fed 
by  the  nasal  tube.  Sedatives,  such  as  bromid  and  chloral, 
are  usually  ordered.  The  tetanus  bacillus  may  be  present 
in  the  wound  secretions.  At  the  present  day  such  cases 
are  usually  isolated  from  other  surgical  cases. 

A  severe  case  of  tetanus  is  very  frequently  fatal.  As 
a  rule,  if  there  is  any  chance  that  a  wound  has  been  con- 
taminated by  soil,  tetanus  antitoxin  is  administered 
without  waiting  for  symptoms  to  develop. 


CHAPTER  XIX 

NURSING    IN    ACCIDENTS    AND    EMERGENCIES 
(Continued) 

Burns  and  Scalds — Immediate  Treatment:  Of  the  Eye;  the 
Throat ;  Dressings — Stages — Physical  Treatment — Complications — 
Burns  by  Lightning,  Electricity — Bites — Stings — Frost-bite — Boils 
— Stye — Carbuncle — Whitlow — Convulsions:  Tonic,  Clonic,  Epilep- 
tiform,  Tetanic — Causes — General  Treatment — Points  to  Observe: 
in  Convulsions;  in  Epilepsy;  in  Alcoholism;  in  Uremia;  in  Children; 
in  Tetanus;  in  Strychnin-poisoning;  in  Hysteria — Foreign  Bodies: 
Eye,  Ear,  Nose,  Throat,  Esophagus,  Larynx — Artificial  Respiration : 
Sylvester  Method;  Marshall  Hall  Method;  Drowning;  Asphyxia  of 
the  New-born  —  Fainting  —  Concussion  —  Heat  Exhaustion  —  Heat 
Stroke. 

BURNS  AND  SCALDS 

BURNS  and  scalds  are  caused  by  the  effect  on  the  soft 
tissues  of  direct  heat.  Burns  are  caused  by  dry  heat — 
fire,  electricity,  red-hot  substances,  or  corrosives;  scalds 
are  the  result  of  moist  heat,  steam,  or  very  hot  fluids. 
In  burns  or  scalds  three  degrees  of  injury  are  recognized: 

(1)  Reddening  of  the  skin;  (2)  destruction  of  the  true 
skin  and  the  formation  of  blisters;  (3)  injury  to  the  deeper 
tissues.  Acute  pain  is  a  prominent  symptom,  especially 
in  burns  of  the  first  and  second  degrees. 

A  scald  is  usually  of  the  first  or  second  degree;  serious 
scalding  is  often  the  effect  of  a  boiler  explosion,  frequently 
involving  an  extensive  portion  of  the  body,  and  generally 
including  the  face. 

The  symptoms  and  treatment  of  burns  and  scalds  are 
the  same  and  will  be  considered  together. 

In  all  such  accidents  the  physical  condition  is  to  'be 
considered  as  well  as  the  local.  Of  the  two,  the  physical 
condition  is  the  more  immediately  important. 

The  extent  of  a  burn  is  a  more  serious  condition  than 
the  depth.  A  superficial  burn  of  large  area  is  more  fatal 
to  life  than  a  deep  burn  of  localized  extent.  A  fatal  result 


BURNS   AND   SCALDS  6(53 

is  looked  for  if  two-thirds  of  the  body  are  involved,  even  if 
only  by  burns  of  the  first  degree. 

Unless  a  burn  is  very  slight  or  very  severe,  it  is  not 
possible,  at  the  time  of  the  accident,  to  estimate  the 
severity  of  the  injury  or  to  determine  the  degree  to  which 
the  burn  may  belong.  Nurses  should  be  very  careful  in 
concluding  that  a  burn  is  slight. 

Immediate  Local  Treatment  (Scalds  are  Included 
under  Burns). — Burns  of  the  first  and  second  degree  cause 
intense  local  pain,  which  is  most  quickly  relieved  by  the 
application  of  a  cold  wet  dressing.  Plain  sterile  water 
may  be  used,  or  a  solution  of  boric  acid  (2  per  cent.)  or 
a  weak  solution  of  bicarbonate  of  soda.  Contact  with  the 
air  increases  the  pain;  the  burn  should,  therefore,  be  cov- 
ered quickly.  The  bandage  must  be  applied  lightly,  as 
some  swelling  is  sure  to  follow,  and  it  is  not  possible  at  the 
time  to  gage  the  extent  of  the  injury.  Any  clothing  must 
be  gently  removed. 

Instead  of  applying  a  cold  wet  dressing,  the  surface  of 
the  wound  may  be  freely  dusted  with  flour  or  bicarbonate 
of  soda  (baking-powder),  and  covered  with  absorbent  cot- 
ton. If  vesicles  form  and  break,  however,  dry  substances 
are  apt  to  cake  and  become  difficult  to  remove.  The 
burn  may  also  be  dressed  with  oil  or  an  ointment  spread  on 
gauze  or  old  soft  muslin.  Such  a  dressing  relieves  pain 
by  effectually  excluding  the  air,  but  is  apt  to  become  hot 
and  uncomfortable.  Any  simple  oil  or  ointment  that  is 
available  serves  for  a  first  dressing;  butter  or  lard  will  also 
answer  the  purpose.  Carron  oil,  an  equal  mixture  of 
lime-water  and  olive  or  cotton-seed  oil,  is  frequently,  in 
homes,  kept  for  such  emergencies. 

If  a  burn  is  caused  by  corrosives,  the  injured  surface 
should  first  be  washed  with  plenty  of  cold  water,  in  order 
to  get  rid  of  the  irritating  substance.  An  antidote  is  used 
if  one  is  available.  For  acid  corrosives,  weak  ammonia  and 
water  or  a  solution  of  bicarbonate  of  soda  may  be  used; 
for  alkaline  corrosives,  vinegar  and  water,  lemon-juice 
and  water,  or  a  dilute  acid  solution.  Boric  acid  is  usually 
available.  The  antidote  to  carbolic  acid  is  alcohol; 
burns  caused  by  carbolic  acid  are  washed  and  dressed  with 


G64       NURSING   IN   ACCIDENTS   AND   EMERGENCIES 

alcohol;  oil  applications  in  this  condition  are  especially 
to  be  avoided  (p.  374),  since  oil  helps  in  the  absorption 
of  carbolic  acid. 

In  burns  of  the  second  degree  the  first  stage  of  conges- 
tion is  followed  in  a  few  hours  by  the  formation  of  vesicles. 
When  fully  risen,  each  blister  is  snipped  at  its  most  de- 
pendent part  with  a  sharp-pointed  pair  of  scissors  and 
gently  pressed  to  allow  the  fluid  to  escape.  The  cuticle 
is  not  cut  away:  it  serves  as  a  natural  protection  to  the 
denuded  surface.  For  the  simple  dressing,  one  containing 
a  mild  non-irritant  antiseptic  is  then  substituted. 

Burns  of  the  third  degree  are  always  serious,  and  if 
involving  more  than  two-thirds  of  the  body,  they  are 
commonly  fatal  in  a  few  hours.  Other  cases  linger  a  few 
days.  If  less  extensive,  recovery  may  take  place,  with  a 
long  and  tedious  convalescence,  or  the  patient  may  suc- 
cumb later  to  one  or  other  of  the  complications  associated 
with  burns. 

Such  burns  are  frequently  the  result  of  the  clothes 
catching  fire.  The  first  examinations  should  ascertain  that 
no  smouldering  is  still  going  on.  The  charred  remains  of 
the  clothes  must  be  removed.  If  the  physical  condition 
permits,  this  is  frequently  done  under  ether;  the  burns 
may  then  be  sprayed  with  peroxid  of  hydrogen,  and  irri- 
gated with  warm  boric  solution.  A  dressing  is  then 
applied — either  an  ointment  dressing  or  a  wet  dressing. 
In  many  cases  of  extensive  injury  the  burns  are  treated 
without  local  dressing.  Two  methods  are  used — the 
"  open  treatment  "  and  immersion. 

In  the  open  treatment  of  burns  the  patient  is  laid 
between  sterile  sheets  and  the  burns  are  freely  dusted  with 
a  sterile  dusting-powder,  usually  stearate  of  zinc.  A 
bed-cradle  is  necessary  to  keep  the  bed-clothes  from  press- 
ing on  the  burns.  The  air,  which  by  this  method  is  not 
excluded,  must  be  kept  at  an  even  temperature.  Where 
the  trunk  of  the  body  is  involved,  the  temperature  should 
not  be  less  than  80°  F.  This  temperature  may  be  main- 
tained by  hot-water  cans,  bags,  etc.,  or  an  electric  light, 
where  one  is  available,  may  be  tied  to  the  bed-cradle  and 
the  outer  air  carefully  excluded  by  the  bed-coverings. 


BURNS  AND   SCALDS  665 

The  patient's  body  then  lies  in  a  closed  cabinet  of  warm 
air.  A  light  of  16  candle-power  is  generally  sufficient. 
(See  p.  111.) 

Immersion  may  be  local  if  a  limb  only  is  injured  (see 
Local  Baths,  Chap.  II),  or  the  entire  body  may  be  placed 
in  a  tub  sufficiently  long  for  the  patient  to  lie  comfortably 
extended.  To  the  water  either  boric  acid  or  bicarbonate 
of  soda  is  usually  added.  (See  Baths.)  The  water  must 
be  changed  at  least  once  a  day.  During  the  process  the 
patient  is  wrapped  in  a  clean  sterile  sheet,  the  burns  being 
meanwhile  dusted  with  a  sterile  dusting-powder.  The 
water  excludes  currents  of  air,  keeps  the  surfaces  clean, 
maintains  the  body  temperature,  and  reduces  the  general 
restlessness.  With  children,  total  immersion  is  especially 
successful. 

Burns  of  the  eye  are  usually  caused  by  a  corrosive  or 
by  an  atom  of  red-hot  metal.  Treatment  must  be  prompt. 
In  burning  by  a  corrosive  the  lids  should  be  held  open  and 
the  eye  freely  irrigated  with  cold  or  tepid  water.  The 
stream  should  be  forcible,  in  order  quickly  to  wash  away 
every  atom  of  the  irritant.  The  eye  may  be  held  directly 
under  a  faucet  if  no  other  means  are  available.  A  little 
vaselin  or  a  few  drops  of  castor  oil  may  then  be  put  be- 
tween the  lids.  Cold  or  iced  compresses  should  be  con- 
tinuously applied  until  surgical  aid  can  be  obtained,  and 
the  patient  kept  lying  down  in  a  room  with  the  light 
shaded.  If,  in  order  to  act  promptly,  unsterile  water  has 
been  used,  the  eye  should,  as  soon  as  possible,  be  douched 
with  warm  boric-acid  solution  (2  per  cent.). 

In  burns  to  the  eye  from  a  red-hot  metal  not  a  moment 
must  be  lost  in  obtaining  surgical  assistance.  Cold  com- 
presses may  be  applied  in  the  mean  time,  but  no  other 
treatment  attempted.  Unskilful  attempts  to  remove  the 
foreign  body  may  involve  extensive  injury  to  the  tissues 
and  result  in  loss  of  the  eye. 

Burns  of  the  mucous  membrane  of  the  throat  are 
common  in  children  from  attempting  to  drink  from  a 
kettle;  they  are  also  caused  by  drinking  corrosive  poisons. 
If  severe,  death  usually  results  from  shock.  Where  treat- 
ment is  possible,  the  patient  is  nursed  in  a  warm  atmo- 


666       NURSING   IN   ACCIDENTS  AND   EMERGENCIES 

sphere,  kept  moist  by  a  steam  kettle  to  which  some  respir- 
atory disinfectant,  such  as  benzoin  or  eucalyptus,  is  added. 
Feeding  is  administered  by  rectum.  Stimulation  is  usually 
given  by  hypodermic.  A  throat  spray,  usually  of  equal 
parts  of  peroxid  of  hydrogen  and  lime-water,  or  of  chlorate 
of  potash  (grs.  v  to  the  ounce),  is  used  every  two  or  three 
hours.  If  swallowing  is  possible,  small  quantities  of  milk, 
bland  drinks,  or  sweet  oil  are  given  repeatedly  by  mouth, 
for  the  local  action,  as  well  as  for  the  purpose  of  nutrition. 
The  pain  of  swallowing  may  be  lessened  by  spraying  the 
throat  with  cocain.  Where  the  swelling  is  great,  trache- 
otomy may  be  necessary.  The  indications  for  trache- 
otomy or  intubation  are  increased  dyspnea  and  cyanosis. 

Dressings. — The  first  dressing  of  a  burn  is  generally 
left  on  for  twenty-four  hours.  On  removal,  any  blisters 
are  snipped,  and  a  dressing  containing  a  mild  antiseptic 
is  substituted.  Vaselin,  to  which  is  added  boric  acid  or 
salol  (of  either,  20  grains  to  the  ounce),  is  commonly  used 
if  an  ointment  dressing  is  preferred.  Carron  oil  is  an 
inexpensive  dressing,  but  becomes  quickly  offensive. 
More  commonly  at  present  burns  are  dressed  with  wet 
dressings.  Warm  normal  salt  solution  is  generally  pre- 
ferred. A  strong  antiseptic  is  not  advisable  on  account  of 
the  risk  of  absorption  from  an  extensive  surface.  To 
prevent  the  dressing  sticking,  the  surface  is  first  protected 
with  strips  of  gutta-percha  tissue.  The  strips  are  kept  in 
a  solution  of  bichlorid  of  mercury,  1  : 2000,  which  is 
washed  off  by  soaking  the  strips  in  salt  solution  before 
applying.  The  dressing  is  remoistened  before  it  gets  dry. 

Dressings  are  usually  changed  daily,  and  must  be  done 
with  strict  aseptic  precautions.  From  the  nature  of  the 
injury  a  burn  is,  in  the  first  instance,  an  aseptic  wound; 
it  can,  however,  readily  become  infected.  If  a  dressing 
sticks,  it  must  be  removed  by  soaking.  Pulling  not  only 
causes  great  pain,  but  may  destroy  the  young  granulations 
or  cause  extensive  bleeding. 

Burns  treated  by  the  open  method  become  covered  with 
scabs  composed  of  dry  discharges.  When  granulation 
is  established,  it  is  usual  to  remove  the  scabs,  a  small  por- 
tion daily,  with  a  pair  of  sterile  forceps. 


BURNS   AND   SCALDS  667 

In  deep  burns  of  the  third  degree  the  tissues  are  devital- 
ized. In  this  condition,  when  the  injury  is  local,  hot 
fomentations,  usually  of  boric  acid,  are  frequently  used, 
until  the  surface  begins  to  discharge  freely. 

The  wound  caused  by  a  burn  runs  a  definite  course, 
with  four  well-marked  stages:  (1)  Congestion;  (2)  vesica- 
tion;  (3)  suppuration;  (4)  granulation. 

The  dressing  of  burns  in  the  first  two  stages  is  as  already 
given.  In  the  third  stage  the  surface  of  the  burns  is 
covered  with  a  copious  discharge,  which  becomes  very 
offensive  if  allowed  to  accumulate.  The  daily  dressing 
is  then  accompanied  by  a  free  irrigation  with  a  warm 
antiseptic  solution,  commonly  boric  acid.  At  this  stage 
picric  acid  is  frequently  substituted,  both  as  a  wet  dressing 
and  for  irrigation  (picric  acid,  40  grains;  alcohol,  |  ounce; 
cold  water,  1  pint).  It  is  antiseptic  and  astringent,  and 
promotes  cleansing  of  the  wound  and  healing.  As  the 
picric  stains  linen  yellow,  old  worn  sheets  should  be  used 
on  the  bed  and  old  night-shirts. 

During  the  stage  of  suppuration  sloughs  become  sep- 
arated and  are  thrown  off.  They  should  be  cut  away  when 
possible.  (See  Sloughs.)  If  the  sloughs  are  deep,  their 
separation  may  cause  secondary  hemorrhage. 

As  the  suppuration  lessens  the  wounds  should  present  a 
surface  of  healthy  granulations.  As  in  general  wounds, 
indolent  granulations  require  stimulating  treatment,  and 
redundant  granulations  are  kept  down  by  an  application  of 
silver  stick  or  blue  stone.  The  healing  of  extensive  sur- 
faces is  slow  and  tedious.  When  the  period  of  suppuration 
is  passed  and  the  surface  is  clean,  the  healing  process  is 
frequently  hastened  by  skin-grafting. 

As  burns  heal,  the  formation  of  the  scar  tissue  is  liable 
to  cause  contraction.  If  the  injury  is  near  a  joint,  this 
may  result  in  permanent  crippling.  The  danger  is  lessened 
by  the  use  of  suitable  splints,  extension,  the  early  practice 
of  passive  movements,  and  by  encouraging  the  use  of  the 
affected  limb  in  spite  of  the  pain  caused  by  the  first  efforts 
to  do  so. 

Physical  Treatment. — As  far  as  life  is  concerned,  the 
physical  treatment  in  an  accident  by  burning  outweighs 


668       NURSING   IN   ACCIDENTS   AND   EMERGENCIES 

in  importance  the  local  treatment.  The  physical  effects 
of  a  serious  burn  are,  at  first,  shock,  extreme  restlessness, 
and  excessive  thirst.  Shock  may  not  be  apparent  at  first, 
but  should  always  be  apprehended,  even  when  the  injury 
appears  comparatively  slight,  and  especially  so  if  the 
patient  is  a  child.  Frequently  the  patient  seems  to  pro- 
gress favorably  to  a  certain  point,  and  then  suddenly 
sinks.  Death  from  shock  occurs  within  twenty-four  hours 
of  the  accident.  (See  Shock.) 

The  immediate  physical  treatment  is  rest  in  bed  and 
quiet,  external  warmth,  and  plenty  of  water  to  drink. 
A  stimulant  is  generally  given,  either  alcohol  or  strychnin, 
and  in  extensive  burns  morphin  is  usually  necessary. 
With  children  opium  is  always  given  with  great  caution. 
Usually  paregoric  is  the  preparation  preferred.  A  purge, 
generally  calomel,  is  commonly  ordered. 

If  the  patient  lives,  the  period  of  shock  is  followed  by  a 
period  of  reaction.  The  temperature,  generally  subnormal 
at  first,  rises,  generally  above  103°  F.;  there  are  continued 
fever,  delirium,  great  restlessness, — the  patient  is  with  dif- 
ficulty kept  in  bed, — and  generally  vomiting  and  diarrhea; 
convulsions  may  be  present,  especially  with  children. 
The  condition  may  pass  into  fatal  coma,  or  death  may  take 
place  from  exhaustion  or  other  complications.  The  urine 
is  scanty  or"  suppressed.  During  this  stage  the  patient 
is  kept  quiet,  with  the  light  shaded;  the  diet  is  liquid,  and 
consists  especially  of  milk,  which  may  be  diluted  with 
lime-water  or  Vichy,  and  albumin-water.  For  the  thirst, 
lemonade  to  which  is  added  cream  of  tartar,  \  ounce  to  a 
pint  (Imperial  drink),  is  given  freely.  Besides  relieving 
the  thirst,  the  cream  of  tartar  assists  elimination  and  stim- 
ulates the  activity  of  the  kidneys.  Bromid  is  usually 
given,  and  the  bowels  are  purged  with  calomel  or  castor  oil. 
If  persistent,  the  vomiting  may  be  relieved  by  hot  applica- 
tions to  the  epigastrium.  Diarrhea  is  usually  treated  with 
astringents  or  opium.  When  the  vomiting  and  diarrhea 
cease,  beef-tea,  broths,  or  beef-juice  is  added  to  the 
diet.  As  the  condition  improves,  semisolids  and,  finally, 
solids  are  given.  During  the  periods  of  suppuration  and 
granulation  the  diet  should  be  highly  nourishing.  Fresh 


BURNS   AND    SCALDS  669 

air,  good  hygiene,  and  cheerful  surroundings  are  important. 
Tonics,  especially  iron  or  bitters,  to  stimulate  the  appetite, 
are  generally  ordered. 

Complications. — The  local  complications  of  a  burn  are, 
as  mentioned  above,  extensive  sloughing,  secondary 
hemorrhage,  and  permanent  contraction  of  the  part;  un- 
sightly scarring  may  be  added.  Embolism  may  occur,  es- 
pecially where  there  has  been  extensive  sloughing  or 
secondary  hemorrhage.  As  in  other  wounds,  a  burn  may 
be  the  medium  of  a  general  infection. 

Patients  suffering  from  burns  are  peculiarly  liable  to 
infection  by  erysipelas  or  by  scarlet  fever.  No  one  in  any 
way  in  contact  with  such  cases  should  be  admitted  near  a 
case  of  burns.  Shivering,  an  abrupt  rise  of  temperature, 
a  sudden  attack  of  vomiting,  and,  in  children,  convulsions, 
are  symptoms  to  be  regarded  with  suspicion.  Erysipelas 
is  especially  likely  to  occur  where  the  face  is  the  seat  of 
injury. 

Septic  absorption  is  liable  to  occur  during  the  period  of 
suppuration.  The  general  condition  is  usually  treated 
by  drugs  that  promote  elimination  and  by  general  stimu- 
lation. 

Other  complications  to  be  apprehended  in  burns  of  any 
extent  are  congestion  and  inflammation  of  the  internal 
organs,  bronchitis,  pneumonia,  nephritis,  and  intestinal 
inflammations.  Bronchitis  and  pneumonia  may  especially 
be  looked  for  after  scalds  of  the  mucous  membrane  of  the 
throat.  Nephritis  and  intestinal  inflammation  are  most 
common  in  extensive  burns  of  the  trunk.  In  a  large  meas- 
ure the  condition  is  caused  by  the  extra  work  thrown  upon 
the  organs  of  elimination  by  destruction  of  a  large  area  of 
the  skin.  Other  causes  are  septic  absorption  and  the  direct 
local  effect  of  the  burn,  which  acts  as  a  powerful  counter- 
irritant,  and,  it  is  considered,  probably  causes  important 
changes  in  the  underlying  structures. 

Burns  about  the  abdomen  are  generally  associated  with 
inflammation  of  the  intestines  and  frequently  with  ulcera- 
tion,  especially  of  the  duodenum.  Death  may  occur  from 
rupture  of  a  duodenal  ulcer  or  from  hemorrhage.  The 
stools  should  be  watched  for  traces  of  blood.  As  the  lesion 


670        NURSING    IN   ACCIDENTS   AND    EMERGENCIES 

is  high,  the  stools  will  have  a  tarry  appearance.  Localized 
abdominal  pain,  acute  or  persistent,  and  distention  are 
important  symptoms  of  this  condition.  The  treatment  is 
the  same  as  in  any  other  case  of  intestinal  hemorrhage  (p. 
615).  Nephritis  is  one  of  the  most  common  complications 
of  extensive  burns.  It  is  characterized  by  headache,  albu- 
minuria  with  scanty  urine,  and  puffiness  of  the  face  and  feet. 
In  severe  cases  hematuria  may  be  present.  The  diet  is 
usually  restricted  entirely  to  milk  as  long  as  albuminuria 
persists.  Elimination  is  aided  by  purgatives  and  diuretics, 
water  or  Imperial  drink  is  given  freely. 

Burns  by  Lightning. — Burns  due  to  lightning,  electricity, 
or  to  prolonged  exposure  to  the  re-rays  may  also  be  met  with. 
A  burn  by  lightning  is  branched  like  a  flash  of  forked 
lightning.  The  patient  is  severely  shocked,  and  frequently 
unconscious.  On  recovery,  loss  of  sensation  and  temporary 
local  paralysis  are  commonly  present;  there  are  frequently 
disturbances  of  vision,  and  the  patient  may  remain  per- 
manently blind. 

The  local  treatment  is  the  same  as  for  burns  from  other 
causes.  The  tissues  are  necrosed  and  healing  is  slow. 

In  treating  the  condition  of  shock  electricity  must  not 
be  used. 

Burns  by  electricity  may  be  slight  or  severe.  The 
shock  is  frequently  fatal.  A  severe  burn  is  practically 
the  same  as  a  burn  by  lightning. 

In  an  accident  by  electricity  it  is  of  immediate  impor- 
tance to  break  the  electric  circuit.  If  an  interruption  is 
at  hand,  this  is  easily  done,  or  if  the  wire  is  insulated  at 
any  available  point,  it  can  be  removed;  if  not,  the  patient 
must  be  pulled  away. 

Until  the  circuit  is  broken,  any  one  touching  the  person 
struck  with  bare  hands  will  also  be  shocked.  Silk  and 
wool  are  non-conductors  if  perfectly  dry.  The  hands  may 
be  closely  wrapped  with  anything  available  of  these  mate- 
rials; the  clothes  of  the  victim  may  then  be  grasped,  and 
he  can  be  pulled  away,  thus  breaking  the  circuit.  If  the 
available  force  is  not  sufficient  to  move  him,  a  thickly  folded 
blanket  should  be  pushed  under  him,  using  which  as  a 
pad  he  may  be  raised  from  contact  with  the  earth,  which 


BITES    AND    STINGS  671 

is  the  other  pole  of  the  circuit,  and  moved  to  a  place  of 
safety.  The  patient  is  unconscious  and  in  an  extremely 
critical  condition. 

The  treatment  must  be  prompt.  The  clothes  are  loos- 
ened, fresh  air  is  admitted,  external  heat  and  stimulation 
of  the  circulation  by  friction,  etc.,  applied.  Artificial  res- 
piration is  usually  necessary,  and  should  be  continued  as 
long  as  the  heart  can  be  felt  to  beat.  Cardiac  stimulants 
may  be  given  by  hypodermic.  Once  respiration  is  re- 
stored, the  subsequent  treatment  is  the  same  as  for  any 
condition  of  shock,  avoiding  only  all  use  of  electricity. 

BITES  AND   STINGS 

The  bite  of  an  animal  inflicts  a  punctured  wound,  which, 
in  the  majority  of  cases,  is  also  lacerated.  The  wounds  are 
usually  slow  in  healing  and  readily  become  infected. 
Superficial  wounds  are  usually  dressed  with  hot  antiseptic 
compresses.  Where  the  puncture  is  deep  or  there  is  dirt 
in  the  wound,  the  usual  treatment  is  to  open  up  the  wound 
freely.  Strong  astringents  or  the  actual  cautery  should  not 
be  applied  unless  there  is  actually  hemorrhage  to  be  con- 
trolled. 

Extensive  bites,  where  the  tissues  are  much  lacerated, 
are  commonly  accompanied  by  extreme  shock.  The 
possibility  of  shock  in  any  case  must  be  borne  in  mind. 

A  bite  by  a  rabid  animal  is  rare,  and  cases  so  reported 
are  frequently  not  authentic.  Many  dogs  in  hot  weather 
suffer  from  heat-stroke.  In  this  condition  they  appear 
mad,  and  if  molested  are  apt  to  bite.  Every  effort  should 
be  made  to  keep  the  dog  alive  and  under  observation — 
expert,  if  possible.  If  the  dog  is  proved  not  to  be  rabid, 
much  needless  anxiety  is  spared  the  victim. 

Until  recently  the  only  treatment  advised  for  such 
wounds  was  instant  cauterization.  It  is  now  considered 
that,  by  thus  sealing  the  tissues,  absorption  of  the  poison 
is  furthered.  The  present  treatment  consists  in  laying 
open  the  wound,  thoroughly  cleansing  the  part  with  anti- 
septics, and  the  application  of  hot  antiseptic  compresses. 
If  the  dog  is  known  to  be  rabid,  the  patient  is  usually  ad- 
vised to  undergo  the  Pasteur  treatment  at  once. 


672        NURSING    IN    ACCIDENTS   AND    EMERGENCIES 

Snake-bite. — The  action  of  the  venom  of  a  snake-bite 
on  the  system  is  similar  to  the  action  of  bacterial  toxins. 
The  poison  acts  directly  on  the  central  nervous  system, 
producing  profound  prostration,  and  sometimes  fatal 
collapse.  The  venom  also  attacks  the  blood-cells  and 
destroys  the  coagulability  of  the  blood.  Extravasations 
of  blood  causing  a  petechial  rash  are  common. 

The  bite  of  even  the  most  venomous  snake  is  not  now 
considered  necessarily  fatal,  provided  treatment  can 
be  prompt.  The  local  treatment  usually  advised  is  to 
apply  a  tourniquet  above  the  bite  (if  in  an  extremity), 
with  the  object  of  preventing  the  poison  from  reaching  the 
general  circulation,  and  to  cover  the  small  wound  with  a 
wet  dressing,  in  order  to  encourage  bleeding.  Cupping  is 
advocated  if  it  can  be  done  immediately.  Cauterization 
is  not  considered  advisable. 

The  physical  treatment  consists  in  rest,  external  heat, 
and  the  free  use  of  stimulants.  Doctors  advise  strychnin 
or  atropin  in  preference  to  the  alcoholic  stimulants;  they 
are,  however,  frequently  not  at  hand.  The  patient  should 
be  reassured  and  encouraged  to  a  hopeful  view  of  his  con- 
dition. 

Stings. — In  a  sting  we  have  a  minute  puncture  into 
which  a  poison  has  been  introduced,  which  has  a  local  irri- 
tant action.  The  poisons  of  insects  are  acid;  the  irritation 
is,  therefore,  best  relieved  by  an  alkaline  application, 
such  as  ammonia,  soda,  common  soap,  or  laundry  blue,  all 
of  which  are  usually  available.  An  acid,  such  as  carbolic 
acid,  also  relieves  irritation  by  causing  a  superficial  anes- 
thesia. 

A  bee  or  wasp  may  leave  its  sting  in  the  wound.  This 
should  first  be  removed  by  pressing  some  hollow  round 
object,  such  as  an  old-fashioned  key,  firmly  on  the  tissue 
immediately  round  the  mark  of  the  bite.  The  area,  which  is 
often  considerably  swollen  and  painful,  may  then  be  bathed 
with  hot  water  and  ammonia,  and  finally  dressed  with  a 
cold  compress  of  dilute  ammonia  water  or  other  alkaline 
preparation.  If  a  patient  has  been  attacked  by  a  swarm 
of  bees,  he  is  probably  in  a  highly  nervous  condition, 
and  may  be  considerably  shocked.  Bromid,  bromid  and 


FROST-BITE    AND   EXPOSURE  673 

chloral,  or  a  small  dose  of  morphin  is  often  necessary. 
The  injured  part  may  be  covered  with  hot  compresses  con- 
taining ammonia,  heat  soothing  pain  more  effectively 
than  cold. 

FROST-BITE  AND   EXPOSURE 

A  frost-bite  is  the  local  result  of  prolonged  exposure 
of  the  body  to  extreme  cold,  most  commonly  occurring  on 
the  more  exposed  parts  of  the  body,  the  fingers  and  toes, 
the  ears,  nose,  and  the  skin  over  the  cheek  bones.  The 
extreme  cold  causes  contraction  of  the  superficial  blood- 
vessels; if  the  circulation  in  the  part  is  not  maintained,  the 
blood-supply  is  entirely  cut  off,  resulting  in  the  death  of 
the  part.  In  mild  cases  a  slough  is  formed;  in  more  severe 
cases,  gangrene  results. 

If  seen  early,  the  part  attacked  has  a  blanched  appear- 
ance, and  should  be  briskly  rubbed  with  a  lump  of  snow  or 
a  cloth  wrung  out  of  ice-cold  water,  taking  care  not  to 
bring  the  sufferer  into  a  warmer  atmosphere  until  the 
normal  color  is  restored.  In  severe  cases,  involving  pro- 
longed general  exposure,  the  patient  may  be  in  a  comatose 
condition.  The  first  treatment  is  then  to  restore  the  cir- 
culation of  the  body.  The  patient  is  laid  in  a  room  of  low 
temperature  (about  50°  F.),  and  the  whole  body  briskly 
rubbed  with  the  hands.  As  the  warmth  of  the  body  returns 
the  temperature  of  the  room  is  gradually  raised  and  the 
body  is  covered  with  warm  blankets.  Hot  drinks  and 
alcoholic  stimulants  may  then  be  given.  If  the  patient 
remains  unconscious,  hot  rectal  irrigation  with  normal  salt 
solution,  coffee  and  brandy  enemata,  and  cardiac  stimu- 
lants by  hypodermic  are  given,  with  the  usual  treatment  for 
shock. 

When  the  circulation  is  restored,  the  local  injuries  are 
dressed.  An  anodyne,  such  as  tincture  of  opium  or  opium 
liniment,  is  frequently  applied  first,  and  the  parts  are 
wrapped  in  absorbent  cotton.  Later,  when  sloughing 
occurs,  hot  antiseptic  applications  may  be  used  to  hasten 
the  separation  of  the  sloughs  and  lessen  the  risk  of  septic 
absorption.  Should  gangrene  result,  the  part  is  enveloped 
in  cotton  until  separation  takes  place,  and  the  surrounding 

4.3 


674       NURSING   IN   ACCIDENTS   AND   EMERGENCIES 

tissues  regularly  rubbed  and  protected  from  changes  of 
atmospheric  temperature.  In  some  cases,  as,  for  example, 
where  the  whole  foot  is  involved,  amputation  becomes 
necessary. 

In  the  after-treatment  the  general  health  must  be  built 
up  by  liberal  diet  and  the  use  of  stimulants  and  tonics. 

BOILS,   STYES,   CARBUNCLES,  WHITLOW 

A  boil  or  furuncle  is  an  acute  local  inflammation  of  a 
hair-follicle  or  sebaceous  gland,  usually  due  to  local  infec- 
tion by  a  pus-producing  organism  (Chap.  XII).  Where 
suppuration  does  not  occur,  the  lesion  is  known  as  a  blind 
boil. 

A  boil  may  be  an  isolated  occurrence.  More  fre- 
quently, boils  tend  to  occur  in  groups  and  to  recur  at 
intervals.  The  condition  is  favored  by  a  debilitated  state 
of  health,  and  especially  by  the  presence  of  chronic  debili- 
tating diseases,  such  as  diabetes  and  nephritis. 

Suppuration  is  hastened  by  the  use  of  hot  compresses 
or  counterirritants,  such  as  ichthyol  ointment.  As  soon 
as  the  local  abscess  has  formed,  the  boil  is  incised.  In  the 
center  will  be  formed  a  small  lump  of  necrosed  tissue. 
The  little  cavity  is  irrigated,  lightly  packed,  and  dressed 
with  a  simple  aseptic  dressing  or  some  astringent  ointment. 
The  application  of  a  caustic,  such  as  crude  carbolic,  to  the 
cavity  is  sometimes  recommended.  The  surrounding 
parts  should  be  carefully  cleansed  with  an  antiseptic  solu- 
tion, to  protect  other  hair-follicles  from  infection. 

Recurrent  boils  may  be  due  to  the  state  of  health,  to 
infection  from  the  existing  boil,  owing  to  scratching  or 
careless  dressing,  or  to  lack  of  cleanliness  in  the  clothing. 
The  care  of  the  general  health  and  the  removal  of  any 
debilitating  cause  are  important  parts  of  the  treatment. 

A  stye  is  a  small  furuncle  occurring  on  the  margin  of  an 
eyelid,  involving  a  hair-follicle.  The  usual  treatment  is 
to  apply  hot  boric  compresses  until  a  small  point  of  suppu- 
ration is  seen  round  an  eyelash;  on  pulling  out  the  eyelash 
a  channel  of  escape  for  the  discharge  is  formed,  and,  after 
a  few  more  applications  of  the  hot  boric  compresses,  the 
inflammation  usually  subsides. 


BOILS,    STYES,   CARBUNCLES,    WHITLOW  675 

A  carbuncle  is  an  acute  inflammation  attacking  the  skin 
and  underlying  tissues,  also  due  to  infection  through  a 
hair-follicle  by  one  of  the  pus-producing  organisms.  The 
infection  spreads  through  the  subcutaneous  tissue,  involv- 
ing a  considerable  area,  and  causing  numerous  local  points 
of  suppuration  and  necrosis.  In  appearance  the  skin  over 
the  area  is  red  and  brawny,  and  pitted  with  numerous 
openings  discharging  pus.  The  necrosed  areas  increase, 
forming  large,  offensive  sloughs,  attended  with  copious 
discharge.  The  condition  is  accompanied  by  the  physical 
symptoms  of  sepsis,  attacks  of  shivering,  fever,  and  great 
prostration.  Patients  are  usually  in  middle  age,  and 
frequently  are  sufferers  from  some  chronic  debilitating 
disease,  especially  diabetes.  From  a  neglected  carbuncle 
general  septicemia  may  result. 

The  usual  site  of  a  carbuncle  is  the  nape  of  the  neck  or 
the  back,  between  the  shoulders;  more  rarely  they  occur  on 
the  buttocks. 

The  surgical  treatment  consists  in  free  cross  incision, 
so  as  fully  to  expose  the  necrosed  areas  and  allow  for 
drainage.  The  sinuses  are  usually  cureted,  or  applica- 
tions of  crude  carbolic  are  used.  Hot  antiseptic  compresses 
are  employed  to  hasten  the  separation  of  the  sloughs.  A 
thorough  dressing  is  given  at  least  once  daily.  The  area 
may  be  syringed  with  peroxid  of  hydrogen,  and  freely  irri- 
gated with  a  mild  antiseptic.  On  account  of  the  exten- 
sive surface,  strong  antiseptics  are  not  used.  The  deeper 
pockets  and  sinuses  are  lightly  packed,  and  sloughs  are 
cut  away  as  soon  as  possible.  The  possibility  of  hemor- 
rhage on  the  separation  of  the  slough  should  not  be  for- 
gotten, and  the  means  of  controlling  it  kept  on  hand. 

The  cure  of  a  carbuncle  is  long  and  tedious.  The  care 
of  the  physical  condition  forms  an  equally  important  part 
of  the  treatment.  Rest  in  bed,  good  hygiene,  and  a  liberal, 
nourishing  diet  are  essential.  Stimulants  are  generally 
given  freely,  and  tonics,  especially  iron,  arsenic,  and  quinin. 
As  in  all  septic  conditions,  elimination  should  be  active. 

A  felon,  whitlow,  or  paronychia  is  a  local  infection  occur- 
ring near  or  under  a  nail.  It  is  frequently  the  result  of 
leaving  exposed  the  small  wound  caused  by  a  pin-prick. 


676        NURSING    IN   ACCIDENTS    AND   EMERGENCIES 

The  inflammation  is  accompanied  by  acute  pain,  owing  to 
the  tension  caused  by  the  limited  area  for  expansion,  due 
to  the  proximity  of  the  bone.  If  not  relieved,  the  infection 
is  liable  to  spread  along  the  lymphatics  and  cause  painful 
enlargement  of  the  glands  in  front  of  the  elbow  and  in  the 
axilla.  Local  suppuration  usually  occurs  rapidly. 

The  usual  treatment  is  to  apply  hot  antiseptic  com- 
presses, followed  by  incision  as  soon  as  suppuration  has 
taken  place.  If  the  patient  can  be  persuaded  to  keep  the 
finger  in  a  hot  antiseptic  bath  (carbolic,  1  :  40,  or  bichlorid 
of  mercury,  1  :  2000),  either  continually  or  for  a  couple  of 
hours  at  a  time,  suppuration  may  frequently  be  averted. 

The  incision  must  be  made  with  the  same  strict  asep- 
tic precautions  observed  in  larger  operations.  The  open- 
ing of  a  small  infected  area  with  a  non-sterile  needle, 
etc.,  is  a  frequent  cause  of  general  septic  infection.  If  the 
discharge  is  imprisoned  by  the  nail,  it  becomes  necessary 
to  cut  away  a  portion  of  the  nail  to  allow  a  channel  of 
escape.  It  is  a  painful  operation,  and  is  generally  done 
under  a  local  anesthetic,  such  as  freezing  the  surface  with 
ethyl  chlorid. 

The  small  cavity  is  usually  cureted,  or,  instead,  an  appli- 
cation of  crude  carbolic  may  be  preferred,  after  which  a 
small  drain  of  gauze  is  inserted  and  a  dressing  applied. 
As  from  the  locality  of  the  wound  the  smallest  tension 
causes  acute  pain,  a  wet  dressing  is  usually  preferred, 
which  favors  the  escape  of  discharge. 

Young  nurses  often  show  a  disposition  toward  repeated 
small  infections  of  this  nature.  The  general  health  should 
be  attended  to,  the  bowels  regulated,  the  appetite  encour- 
aged, and  a  certain  amount  of  time  spent  daily  in  the  open 
air.  Tonics,  especially  the  iodid  of  iron  or  the  elixir  of 
iron,  strychnin,  and  quinin,  are  frequently  prescribed. 
Nurses  should  be  taught  to  cover  all  pricks  and  scratches 
at  once.  The  application  of  a  light  collodion  dressing  is 
sufficient  to  protect  from  infection. 

If  a  felon  is  neglected,  the  suppuration  may  spread  to  the 
deeper  tissues  involving  the  periosteum,  and  possibly  lead 
to  the  destruction  of  a  portion  of  the  bone.  The  whole 
finger  is  inflamed  and  acutely  painful.  The  usual  treat^ 


CONVULSIONS  677 

ment  is  free  and  deep  incision,  without  delay.  The  wound 
is  kept  open  by  a  drain  of  gauze,  etc.,  over  which  a  wet 
antiseptic  dressing  is  applied.  If  a  sequestrum  forms,  the 
wound  will  not  heal  until  the  fragment  of  bone  has  sepa- 
rated and  been  removed.  In  such  a  condition  the  physical 
symptoms  are  usually  severe.  Shivering,  fever,  and  the 
general  disturbances  of  a  septic  condition  are  present. 
They  are  treated  with  free  purging,  rest  in  bed,  and  a 
liquid  diet  as  long  as  the  fever  lasts,  after  which  a  liberal 
diet,  the  use  of  tonics,  and  good  hygiene  are  the  general 
lines  of  treatment. 

CONVULSIONS 

By  the  term  convulsion  is  understood  a  paroxysm  in 
which  the  voluntary  muscles  are  contracted  involuntarily. 
The  convulsion  maybe  general  or  local;  the  muscular  con- 
tractions continuous  or  intermittent. 

Continuous  contractions  are  called  tonic;  intermittent, 
clonic.  A  convulsion  usually  begins  abruptly  and  is  of 
short  duration. 

In  a  tonic  convulsion  the  muscles  are  strongly  contracted, 
the  limbs  forcibly  extended,  the  head  retracted,  and  the 
body  held  rigid  in  a  forced  position;  the  spine  may  be  com- 
pletely arched  (opisthotonos). 

A  clonic  convulsion  is  characterized  by  abrupt  jerky 
movements  of  the  affected  part.  The  two  forms  may  occur 
in  the  same  seizure,  and  frequently  follow  each  other. 

Convulsions  are  considered  in  two  principal  groups: 
those  in  which  consciousness  is  lost  and  those  in  which,  if 
present,  it  is  retained. 

The  first  group  is  known  as  epileptiform,  the  second  as 
tetanic;  epileptiform  convulsions  are,  in  common  tongue, 
spoken  of  as  fits. 

Epileptiform  convulsions  occur  in  epilepsy;  in  conditions 
causing  pressure  to  the  brain,  as  apoplexy,  fractured 
skull,  brain  tumor;  in  meningitis,  uremia,  alcoholism,  and 
in  poisoning  by  certain  drugs.  In  young  children  epilepti- 
form convulsions  are  common  as  the  result  of  reflex  irri- 
tation in  many  conditions;  common  causes  are  gastric 
disturbances,  intestinal  worms,  teething,  the  onset  of  an 


C78        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 

acute  illness,  especially  of  the  infectious  fevers,  and  in  any 
other  condition  associated  with  rise  of  temperature. 

In  an  epileptiform  convulsion  there  is  usually  a  compar- 
atively short  tonic  contraction,  followed  by  a  longer  period 
of  clonic  contractions.  A  characteristic  feature  is  the 
closing  of  the  hand  over  the  inverted  thumb.  The  eyes 
squint  and  are  turned  upward;  the  sphincters  are  re- 
laxed, urine  and  frequently  also  the  bowel  movements  are 
passed  unconsciously;  there  is  usually  foaming  at  the 
mouth;  the  face  is  flushed,  or  may  be  first  violently  flushed, 
then  pale. 

Tetanic  convulsions,  as  the  name  shows,  are  character- 
istic of  tetanus,  or  lock-jaw.  They  occur  also  in  poisoning 
by  strychnin,  in  the  condition  known  as  tetany,  and  are  the 
usual  form  of  the  hysteric  convulsion.  The  contractions 
may  be  clonic  or  tonic.  Prolonged  tonic  contractions  are 
characteristic. 

In  the  general  treatment  of  a  convulsion  the  patient 
should  be  placed  where  he  cannot  hurt  himself;  the  clothing 
should  be  loosened,  and  a  cork  or  small  object  placed 
between  the  teeth  to  prevent  the  tongue  being  bitten. 
The  movements  may  be  guided,  but  should  not  be  re- 
strained. 

During  a  convulsion  the  patient  must  not  be  left.  A 
message  should  be  sent  to  summon  medical  aid;  in  the 
mean  time  close  accurate  observation  of  the  symptoms  may 
be  an  important  aid  to  diagnosis. 

The  chief  points  to  be  observed  are  as  follows: 

1.  Whether   the   convulsions   are   tonic   or   clonic,   or 
whether  one  condition  follows  the  other. 

2.  The  area  affected — whether   the   whole   body,  one- 
half  of  the  body,  or  confined  to  a  localized  area. 

3.  The  point  at  which  the  movements  are  first  manifested, 
and  the  order  in  which  the  other  muscles  become  affected. 

4.  The  length  of  duration. 

5.  Twitchings  of  the  facial  muscles  and  the  side  toward 
which  they  are  drawn;  squinting;  contraction,  dilatation, 
or  irregularity  of  the  pupils;  frothing  of  saliva  at  the  mouth. 

6.  Relaxation  of  the  sphincters,   causing  involuntary 
voiding  of  urine  or  action  of  the  bowels. 


CONVULSIONS  679 

7.  Changes  in  the  pulse  or  respiration. 

8.  Lividity  or  flushing  of  the  face. 

9.  Premonitory  symptoms,   such   as   sharp   cry,   great 
restlessness,  apprehension,  etc. 

Important  points  should  be  noted  on  the  record  chart, 
together  with  the  hour  of  the  occurrence  of  the  attack. 

Special  treatment  is,  of  course,  directed  toward  treat- 
ing the  underlying  cause  and  quieting  the  nerve-centers. 
In  most  conditions  of  epileptiform  convulsions  elimination 
is  furthered  by  a  quickly  acting  cathartic. 

Epilepsy. — True  or  idiopathic  epilepsy  is  a  chronic 
disease  characterized  by  failing  mentality  and  recurrent 
convulsions.  The  attack  is  preceded  by  a  loud  cry,  and 
the  patient  falls  heavily  where  he  stands.  Frequently 
there  is  decided  premonition  of  the  attack,  accompanied 
by  some  one  peculiar  sensation,  which  is  known  as  the  aura. 
The  convulsion  involves  the  whole  body;  consciousness  is 
recovered  immediately  the  convulsion  is  over.  After  an 
attack  the  patient  is  induced  to  rest,  and  usually  sleeps 
heavily.  The  bromids  are  generally  prescribed,  and  the 
bowels  purged. 

Where  the  convulsion  is  the  result  of  injury  to  or  acute 
disease  of  the  brain,  the  treatment  is  the  general  treatment 
of  the  condition.  The  convulsions  are  generally  confined 
to  a  definite  locality,  and  sometimes  only  the  face  or  one 
limb,  at  others  one-half  the  body,  may  be  involved.  The 
convulsions  are  usually  of  the  clonic  variety.  Conscious- 
ness is  not  recovered  between  the  attacks,  which  are  often 
prolonged  indefinitely. 

The  convulsions  of  alcoholism  and  uremia  bear  many 
points  of  resemblance.  In  both  there  is  frequently  noisy 
delirium,  and  the  convulsions  may  at  first  be  mistaken  for 
violent  voluntary  movements.  Later  the  convulsions  of 
uremia  are  markedly  epileptiform,  with  coma,  more  or  less 
profound,  between  the  attacks. 

To  mistake  the  two  conditions  is  an  error  that,  should 
the  case  be  one  of  uremia,  might  cost  the  patient  his  life. 

Both  conditions  are  the  result  of  poisons  in  the  blood 
acting  on  the  nerve-centers.  In  a  case  of  alcoholism,  the 
poison  having  been  ingested  by  the  natural  means,  it  can 


680        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 

be  withheld,  and  can  be  eliminated  by  the  natural  excre- 
tions of  the  body.  Recovery  is  generally  anticipated. 
In  a  case  of  uremia  the  poison  is  a  natural  product  of  the 
bodily  activity,  by  far  the  larger  proportion  of  which  is 
excreted  in  the  urine,  but  which,  owing  to  the  failure  of  the 
kidneys  to  perform  their  function,  has  found  its  way  into 
the  blood.  As  long  as  life  is  present  this  poison  must  con- 
tinue to  be  formed  and  to  accumulate  until  the  organs  of 
elimination — the  kidneys,  the  skin,  and  the  bowels — can 
adequately  fulfil  their  function.  Uremia  is  a  very  grave 
condition,  and  not  infrequently  fatal.  It  occurs  in  condi- 
tions of  nephritis,  either  due  to  disease  or  other  causes. 

The  marked  smell  of  alcohol  on  the  breath  in  one  case, 
and  of  a  urinous  odor  on  the  other,  will  suggest  the  con- 
dition; on  the  other  hand,  it  must  be  remembered  that 
the  first  treatment  of  any  abnormal  condition  among 
bystanders  is  usually  to  give  alcohol;  the  odor  may  be, 
therefore,  misleading. 

The  prominent  characteristic  symptom  of  uremia  is  the 
state  of  the  urine.  It  is  either  scanty  or  entirely  sup- 
pressed. What  there  is  is  loaded  with  albumin.  In  alco- 
holism the  urine  will  probably  be  passed  freely. 

Two  other  points  may  be  noticed.  In  uremia  the  coma  is 
profound :  in  alcoholism  the  patient  can  generally  be  roused 
by  shouting  or  violence.  In  uremia  the  pupils  are  usually 
contracted:  in  alcoholism  they  are  dilated.  In  alcoholic 
seizure  the  pulse  is  full  and  quickened:  in  uremia  it  is 
usually  slow  and  of  high  tension. 

In  hospital  work  the  nurse  will  obviously  not  have  the 
responsibility  of  either  the  decision  or  the  treatment.  She 
should,  however,  always  remember  to  save  carefully  any 
urine  that  can  be  obtained  for  examination,  and  to  examine 
the  clothing  for  evidence  of  urine  recently  passed.  In  pri- 
vate work  it  may  occur  that  she  is  called  upon  to  give  first 
aid  in  such  a  case,  and  she  should  realize  the  possible 
gravity  of  the  condition  and  see  that  medical  aid  is 
promptly  secured. 

In  alcoholic  convulsions  the  treatment  consists  in  ad- 
ministering an  emetic  or  giving  lavage,  and  in  furthering 
elimination  by  a  drastic  purge,  such  as  croton  oil  (1  to  3 


CONVULSIONS  681 

minims) .  The  patient  is  prevented,  by  shouting,  shaking, 
cold  affusion,  etc.,  from  sinking  into  coma.  Fresh  cold 
air  should  be  admitted  freely.  Cardiac  stimulants  are 
given  if  the  pulse  shows  signs  of  heart  failure.  If  there  is 
much  delirium,  an  enema  containing  bromid  and  chloral 
in  full  doses  is  frequently  prescribed.  The  after-symptoms 
of  nervousness  are  treated  according  to  their  severity 
with  various  narcotics.  Acute  gastritis  is  commonly 
present,  and  is  treated  with  rest,  light  diet,  and  purgatives. 
In  uremia  the  most  urgent  necessity  is  to  produce  active 
elimination.  To  induce  the  skin  to  act  the  patient  is 
usually  placed  promptly  in  a  sweat-bath  or  a  hot  pack 
(see  Chap.  II);  at  the  same  time  pilocarpin  (J  grain)  is 
given  hypodermically,  and  a  drastic  purge,  such  as  croton 
oil  (1  to  3  minims)  or  elaterium  (^  grain),  is  administered 
by  mouth.  The  sweat-baths  or  packs  are  continued  until 
profuse  sweating  is  produced,  and  repeated  at  intervals 
of  two  to  four  hours.  The  greatest  care  must  be  taken  not 
to  chill  the  surface  of  the  skin  by  exposure  while  giving  the 
treatment.  If  possible,  such  cases  are  best  treated  in  a 
small  room  or  ward,  where  the  remperature  can  be  evenly 
maintained  at  70°  to  80°  F.  At  the  same  time,  it  is  of  the 
first  importance  that  the  air  be  fresh,  and  not  allowed  to 
become  exhausted  and  the  means  of  further  poisoning. 
During  the  convulsions  inhalations  of  chloroform  are 
given,  or  chloral  in  full  doses  is  prescribed  by  enema. 
In  robust  patients  venesection  is  frequently  performed,  and 
from  half  a  pint  to  a  pint  of  blood  removed,  followed  by  the 
injection  into  the  veins  of  one  to  two  pints  of  normal  salt 
solution.  Hot  normal  salt  solution  is  also  given  by  hypo- 
dermoclysis  or  by  rectum,  with  the  object  of  diluting  the 
toxin  in  the  blood.  Dry  cupping  over  the  loins  is  also  a 
treatment  frequently  prescribed.  If  cyanosis  is  marked, 
inhalations  of  oxygen  are  necessary,  but  it  should  be  re- 
membered that  the  condition  may  be  due  to  the  exhausted 
atmosphere  of  the  room,  and  fresh  air  admitted  may 
improve  the  condition.  Between  the  convulsions  the 
patient  may  be  partially  conscious,  wildly  delirious,  or  sink 
into  a  profound  coma.  If  conscious,  he  may  complain 
of  headache,  vertigo,  or  total  blindness.  The  attacks  fol- 


682        NURSING   IN   ACCIDENTS   AND    EMERGENCIES 

low  each  other  with  more  or  less  rapidity.  Sometimes 
hardly  any  pause  is  perceptible  between  the  convulsions. 
Such  a  state  is  described  as  the  status  epilepticus. 

If  the  patient  recovers,  the  treatment  consists  in  rest 
in  bed,  a  diet  chiefly  of  milk  and  farinaceous  foods,  and 
the  use  of  sweat-baths  until  the  albumin  has  disappeared 
from  the  urine,  and  free  purging,  usually  with  salines. 
Headache,  vertigo,  and  disturbances  of  vision  are  symp- 
toms that  are  persistent.  There  may  be  temporary  total 
blindness.  The  patients  are  usually  extremely  anemic, 
and  require  tonics,  such  as  iron,  and  plenty  of  fresh  air 
and  sunlight. 

Uremia  may  occur  as  a  complication  in  pregnancy, 
labor,  or  during  the  puerperium.  It  is  then  known  as 
eclampsia.  Correctly  speaking,  the  term  eclampsia  may  be 
employed  in  any  convulsive  seizure  from  a  temporary 
cause,  as,  for  example,  the  reflex  convulsions  of  children. 
Generally,  the  use  of  the  term  is  restricted  to  the  above 
condition.  Where  the  case  is  serious,  abortion  is  generally 
produced,  or  the  actual  labor  hastened  by  artificial  dila- 
tation and  the  use  of  forceps.  After  delivery  the  symptoms 
usually  quickly  improve.  In  other  respects  the  treatment 
is  the  same  as  described  above. 

Convulsions  in  children  signify  less  than  the  same 
condition  in  adults;  their  nervous  centers  being  in  a  less 
stable  condition,  are  easily  upset  by  minor  causes.  The 
gravity  of  the  condition  depends  on  the  cause  (see  above). 
In  excitable  children  violent  emotion  may  be  sufficient 
cause. 

The  customary  treatment  during  the  convulsion  is 
immersion  in  a  hot  tub-bath  (100°  F.,  rising  to  105°  F.), 
with,  at  the  same  time,  the  application  of  cold  to  the  head. 
The  bath  is  usually  prolonged  until  relaxation  is  complete, 
and  repeated  if  the  convulsions  recur  (p.  683).  An  enema 
is  generally  given  at  once,  followed  by  a  purgative,  com- 
monly castor  oil  or  calomel,  the  dose  according  to  the  age. 
The  convulsions  are  apt  to  recur  at  intervals  until  the  con- 
dition has  been  relieved,  or,  if  ushering  in  an  acute  illness, 
until  the  period  of  invasion  is  over.  The  temperature  is 
generally  raised,  sometimes  very  high;  the  pulse  is  full  and 


CONVULSIONS  683 

rapid.  If  a  child  is  very  restless  or  delirious,  a  hot  pack 
in  which  he  can  remain  for  an  hour  or  more  is  often  more 
efficaceous  than  the  hot  tub. 

Convulsions  of  Tetanus. — Tetanic  convulsions,  so  called, 
are  chiefly  tonic  in  character,  and  accompanied  by  extreme 
pain.  The  convulsion  is  aggravated  by  any  small  disturb- 
ance, such  as  a  touch  or  a  sudden  noise.  A  leading  char- 
acteristic is  the  stiffening  of  the  muscles  of  the  jaw, 
finally  causing  lockjaw  (trismus). 

As  we  have  already  seen,  tetanus  occurs  only  from  infec- 
tion by  the  tetanus  bacillus,  introduced  through  a  wound 
by  direct  inoculation,  and  most  commonly  developing  in 
punctured  wounds  contaminated  by  soil  or  other  dirt. 

The  first  symptom  is  a  difficulty  in  swallowing,  with  a 
feeling  of  stiffness  about  the  jaws.  The  first  suggestion 
of  such  a  symptom  must  be  promptly  reported.  The 
stiffness  gradually  extends  to  the  neck,  the  shoulders,  the 
back  (which  becomes  completely  arched),  the  abdomen, 
and  extremities;  not  infrequently  the  arms  remain  free. 
The  contractions  are  almost  entirely  tonic.  The  muscles 
remain  rigid  between  the  convulsions;  consciousness  is 
not  lost  during  the  attacks.  The  seizure  is  usually  accom- 
panied by  profuse  sweating  and  fluctuations  of  tempera- 
ture. In  a  mild  form  of  tetanus  the  spasm  is  confined  to 
the  head  and  shoulders,  and  the  jaw  is  not  completely 
locked.  Where  the  larger  part  of  the  body  is  involved  and 
the  jaw  completely  locked,  the  condition  is  very  frequently 
fatal.  (See  also  p.  661.) 

Convulsions  from  strychnin  poisoning  closely  resemble 
those  of  tetanus.  The  first  symptom  is,  usually,  some 
mental  exaltation,  with  sharpening  of  the  special  senses, 
especially  that  of  hearing;  the  spasms  begin  in  the 
extremities,  with  twitchings  (clonic  contractions)  of  the 
fingers  and  toes.  Tonic  contractions  follow,  extending 
over  the  whole  body,  and  involving  the  jaw  last.  As  in 
tetanus,  in  acute  cases  the  back  is  completely  arched. 
The  muscles  are  relaxed  between  the  convulsions;  conscious- 
ness is  not  lost.  The  pain  is  frequently  agonizing.  (See 
Poisons,  p.  385.) 

During  the  course  of  spinal  meningitis  rigidity  and  tonic 


684        NURSING   IN   ACCIDENTS   AND   EMERGENCIES 

contractions  of  the  muscles  of  the  back  and  shoulders, 
associated  with  local  tenderness  and  pain,  are  character- 
istic symptoms.  The  paroxysms  occur  at  intervals. 
During  a  paroxysm  the  back  may  be  so  completely  arched 
that  the  soles  of  the  feet  rest  on  the  back  of  the  head. 
The  treatment  is,  of  course,  that  of  the  underlying  dis- 
ease. 

Tetany,  a  disease  seen  usually  in  rickety  children,  is  also 
characterized  by  tonic  contractions  of  the  legs  and  arms, 
usually  occurring  in  paroxysms.  The  limbs  are  contracted 
toward  the  median  line  of  the  body,  the  feet  being  turned 
in  until  .the  soles  meet.  Hot  baths  are  sometimes  used  to 
favor  relaxation,  but  the  chief  treatment  is  directed  toward 
the  underlying  cause  and  the  reestablishment  of  health. 

A  hysteric  convulsion  may  simulate  any  of  the  above 
forms.  It  is  a  characteristic  symptom  that,  as  'a  rule,  no 
one  group  of  symptoms  is  followed  exactly.  The  patient 
is  not  unconscious,  but  keeps  the  eyes  persistently  closed, 
and  resists  attempts  to  open  them.  He  can  generally  be 
roused  by  sharp  pressure  on  the  supra-orbital  notch.  The 
sphincters  are  not  relaxed,  the  pupils  react  to  light,  the 
pulse  remains  unchanged,  and  the  face  is  neither  pallid 
nor  deeply  flushed.  If  the  patient  falls,  it  is  in  a  position 
where  he  will  not  hurt  himself.  He  may  be  noisy,  and 
simulate  delirium  or  mania,  or  perfectly  quiet,  as  though 
comatose. 

Opinions  and  practice  vary  greatly  as  to  the  treatment 
of  hysteria.  To  some  extent  the  treatment  is  always  one 
of  suggestion.  If  a  nurse  is  with  such  a  case,  she  must 
realize  that  only  by  perfect  control  herself  can  she  control 
or  help  her  patient.  Scolding  and  punishments  rarely 
obtain  desired  results.  Nurses  must  frequently  be  warned 
against  treating  hysteria  as  though  it  were  a  mere  display 
of  childish  temper.  For  the  time  the  patient  is  in  an  ab- 
normal condition.  Where  possible,  pains  should  be  taken 
to  get  at,  either  through  the  friends  or  from  the  patient, 
the  underlying  cause  of  the  attack.  It  may  be  mental,  the 
result  of  shock,  grief,  or  worry,  or  physical,  due  to  alcohol- 
ism or  possibly  some  debilitating  disease.  In  nervously 
constituted  patients,  especially  women,  minor  causes, 


REMOVAL   OF   FOREIGN    BODIES 


685 


such  as  constipation  or  the  monthly  period,  may  induce 
hysteric  outbursts.  In  every  case  possible  the  removal  of 
the  cause  is  the  first  step  in  successful  treatment. 

REMOVAL   OF  FOREIGN  BODIES 

A  foreign  body  in  the  eye  causes  pain  and  local  irrita- 
tion, shown  by  the  increased  secretion  of  tears  and  con- 
gestion of  the  blood-vessels  of  the  conjunctiva.  If  this 
condition  is  unrelieved,  serious  inflammation  may  result. 
The  patient  should  first  be  directed  to  keep  the  eyelid 
closed,  and  refrain  from  rubbing  the  eye,  which  may  embed 


Fig.  207. — Evorsion  of  the  upper  lid  (Manhattan  Eye,  Ear,  Nose 
and  Throat  nursing  book). 

the  particle  in  the  eyeball.  Allowing  a  few  seconds  for 
the  tears  to  collect,  the  nose  is  smartly  blown,  and  the 
particles  will,  in  many  cases,  be  found  to  be  washed  by  the 
tears  down  the  lacrimal  canal  into  the  nose.  A  second 
method  is  to  take  the  upper  lid  by  the  lashes  and  pull  it 
well  over  the  under  lid,  by  which  movement  the  particle 
may  be  swept  on  to  the  cheek.  Failing  these  means, 
(lie  lids  should  be  everted.  The  lower  part  of  the  con- 
junctival  sac  is  freely  exposed  by  pulling  the  under  lid 


686       NURSING   IN   ACCIDENTS   AND   EMERGENCIES 

down  toward  the  cheek  bone,  and  directing  the  patient  to 
look  upward.  The  upper  lid  is  taken  by  the  lashes  and 
turned  upward  and  backward.  The  movement  is  made 
easier  by  placing  a  probe,  a  knitting-needle,  etc.,  on  the 
lid,  over  which  it  is  turned.  At  the  same  time  the  patient 
should  be  told  to  move  the  eyeball  freely  about,  so  that  the 
surface  may  be  examined.  The  fragment  is  removed  by 
a  gentle  wiping  movement,  using  a  camel's-hair  brush,  a 
feather,  or  some  soft  clean  material.  No  force  must  be 
used.  If  the  eye  is  irritated  and  painful  after  the  removal, 
a  warm  boric  douche  may  be  given,  and  a  little  white 
vaselin  or  a  few  drops  of  sweet  or  castor  oil  be  laid  between 
the  lids  and  a  pad  and  bandage  applied  for  a  short  time. 


Fig.  208. — The  upper  eyelid  everted  (Pyle). 

Should  the  fragment  not  be  perceptible,  a  douche  of 
warm  boric  solution  should  be  given,  or  the  eye  held  open 
in  a  basin  of  warm  water  and  the  lids  shut  and  opened 
rapidly.  If  the  fragment  is  seen  to  be  embedded  in  the  eye- 
ball or  fails  to  be  removed  by  the  simple  means  described, 
surgical  assistance  should  be  at  once  obtained.  In  all 
cases  of  injury  to  the  eye  prompt  treatment  is  an  urgent  neces- 
sity. In  some  cases  the  fragment  may  be  so  small  as  to 
be  imperceptible  without  a  lens.  In  others,  especially 
with  fragments  of  metal  from  machinery,  the  fragment  may 
be  driven  deep  into  the  tissues  of  the  eyeball. 

Foreign  Body  in  the  Ear. — In  the  case  of  children  a 
foreign  body  in  the  ear  is  usually  a  pea  or  some  small  object 


REMOVAL   OF   FOREIGN   BODIES  687 

poked  in  in  mischief.  Occasionally  an  insect  crawls  in 
the  ear  and,  by  the  noise  of  its  movements,  causes  acute 
discomfort. 

No  attempt  should  be  made  to  remove  the  body  with 
a  probe,  a  pair  of  forceps,  a  hair-pin,  or  other  object.  To 
do  so  will  almost  certainly  push  the  object  further  in,  and 
may  injure  the  tissues. 

The  patient  is  laid  on  the  side,  the  affected  ear  uppermost. 
The  ear  is  then  filled  with  a  little  warm  sweet  oil  dropped 
from  a  pipet;  the  object  will  probably  float  to  the  top,  and 
is  easily  removed. 

To  remove  an  insect  the  same  method  may  be  used,  or 
a  plug  of  cotton  saturated  with  vinegar  or  with  strong 
salt  and  water  can  be  inserted  in  the  ear.  Over  the  plug 
a  pad  is  held  firmly  and  the  patient  directed  to  lie  on  the 
affected  side.  On  removal  after  a  short  time  the  insect 
will  generally  be  found  on  the  plug. 

Syringing,  unless  done  by  experienced  hands,  is  liable 
to  wash  the  object  further  in.  Vegetable  substances  (as 
a  pea)  should  not  be  moistened,  as  they  swell  and  become 
more  difficult  to  remove.  A  small  hard  substance  that 
will  not  float  may  require  gentle  syringing.  (See  Ear 
Douche,  p.  117.) 

A  foreign  body  in  the  nose  is  also  generally  the  result 
of  mischievous  poking.  Small  objects  may  sometimes 
be  dislodged  by  violent  sneezing  excited  by  pepper  or  snuff 
or  by  blowing  hard  down  the  affected  nostril  while  the 
other  is  held  compressed.  If  these  means  fail,  a  nasal 
douche  may  be  gently  given  through  the  unaffected  nostril 
(see  Nasal  Douche),  unless  the  substance  is  one  that  will 
swell  with  moisture.  If  the  object  is  immovable,  surgical 
aid  must  be  sought.  If  this  is  not  procurable,  an  attempt 
may  be  made  to  snare  the  object  with  a  small  loop 
made  of  a  piece  of  clean  wire.  If  the  tissues  are  at  all 
scratched,  the  removal  should  be  followed  by  a  warm 
boric  douche. 

Foreign  Body  in  the  Throat. — Small  substances,  such  as 
particles  of  food,  are  frequently  dislodged  by  drinking 
water  or  swallowing  a  morsel  of  well-chewed  bread.  A 
larger  substance  may  lodge  near  the  top  of  the  esophagus 


688        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 

and  cause  acute  pain,  choking,  and  possibly  asphyxia, 
from  pressure  on  the  windpipe. 

The  esophagus  is  an  elastic  tube.  Near  the  top,  how- 
ever, its  expansion  is  restricted  by  the  one  complete 
cartilaginous  ring  in  the  formation  of  the  trachea.  It  is  at 
this  point  that  hard  substances  are  liable  to  stick.  A 
sharp  slap  between  the  shoulders  will  frequently  dislodge 
the  substance,  sending  it  into  the  mouth  or  below  the  point 
of  obstruction,  when  it  can  readily  pass  into  the  stomach. 
To  be  more  effectual,  a  child  may  be  held  inverted,  or  a 
larger  person  directed  to  lean  forward  over  the  back  of  a 
chair.  If  this  does  not  avail,  water  or  bread  may  be  swal- 
lowed or  vomiting  induced  by  pushing  the  finger  down  the 
back  of  the  throat.  If  the  patient  is  quiet,  it  is  often  quite 
easy  to  reach  the  object  with  the  finger  and  remove  it 
or  force  it  beyond  the  obstruction. 

A  fish-bone  or  other  sharp  substance  embedded  in  the 
tissue  of  the  throat,  if  it  can  be  seen,  is  generally  easily 
removed  by  a  pair  of  forceps,  the  patient  holding  his 
throat  open  in  a  good  light,  and  the  tongue  held  down  with 
a  spoon  or  other  suitable  object.  If  it  cannot  be  seen,  the 
patient  should  be  taken  to  a  doctor,  who  will  remove  it 
with  an  instrument  known  as  the  horsehair  probang. 

A  probang  is  an  instrument  used  in  esophageal  treatment, 
resembling  a  bougie,  and  usually  made  of  gum  elastic. 
For  ordinary  treatments  a  small  sponge  is  attached  to  one 
end.  The  horsehair  probang  has,  near  the  point,  an  inter- 
ruption filled  with  a  skein  of  fine  stiff  hairs.  On  pulling 
on  a  wire  inserted  in  the  probang,  the  point  is  pulled 
toward  the  operator  and  the  hairs  stick  out  all  round, 
very  much  like  an  open  umbrella.  The  foreign  body 
becomes  enmeshed  in  the  hairs,  and  is  thus  removed. 
Where  more  solid  objects,  such  as  coins  or  buttons,  are 
lodged  in  the  esophagus,  a  special  probang,  called  the  coin- 
catcher,  is  used.  In  this,  the  tip  of  the  bougie  is  provided 
with  small  flat  pockets.  It  is  inserted  beyond  the  object, 
and  when  withdrawn  may,  if  the  object  is  movable,  catch 
it  in  one  of  the  pockets.  A  coin  permanently  lodged  in 
the  esophagus  is  not  an  uncommon  accident  with  children ; 
it  causes  partial  stricture,  shown  in  the  inability  to  swallow 


REMOVAL   OF    FOREIGN    BODIES 


089 


solid  foods.  Should  the  coin-catcher  fail  to  recover  the 
object,  it  is  located  by  means  of  an  axray  photograph  and 
removed  by  a  surgical  operation. 

If  a  sharp  substance,  such  as  a  fruit-stone,  fish-bone,  pin, 
or  a  small  toy,  has  been  swallowed,  means  must  be  taken  to 
prevent  injury  to  the  mucous  membrane  of  the  alimentary 
canal.  Purgatives  should  not  be  given  at  first.  The 
patient  should  eat  liberally  of  cereal  or  new  bread,  sub- 


Fig.  209. — Esophageal  instruments:   A,  B,    Forceps;   C,  horsehair 
probang;  D,  coin-catcher;  E,  esophageal  bougie  (Da Costa). 

stances  in  which  the  object  may  become  embedded.  A 
couple  of  hours  after  he  should  be  given  a  meal  of  figs, 
prunes,  or  cooked  apples,  which  will  act  as  a  gentle  purga- 
tive. The  stool  should  be  examined  for  the  missing  object. 
Foreign  bodies  in  the  larynx  or  trachea  consist  usually  of 
fluid  or  food-particles  lodged  there  as  the  result  of  choking, 
vomiting,  or  in  consequence  of  paralysis  of  the  soft  palate. 
Their  presence  causes  dyspnea  and  coughing,  which  may 
result  in  the  ejection  of  the  irritating  substance.  In 

44 


690       NURSING   IN   ACCIDENTS  AND   EMERGENCIES 

this  circumstance  a  blow  on  the  back  will  only  deprive  the 
patient  further  of  breath  and  make  matters  worse. 

If  the  patient  becomes  asphyxiated,  artificial  respiration 
should  at  once  be  begun,  and  surgical  aid  immediately 
secured.  Laryngotomy  or  tracheotomy  may  be  necessary 
in  order  to  remove  the  foreign  body  and  to  enable  the 
patient  to  breathe. 

A  fluid  in  the  larynx,  while  producing  symptoms  less 
immediately  alarming  than  those  caused  by  a  solid  sub- 
stance, is  nevertheless  more  difficult  to  remove  entirely. 
Some  portion  will  almost  certainly  escape  down  the  trachea; 
in  the  lungs  it  becomes  decomposed,  and  is  frequently  the 
cause  of  septic  pneumonia.  Where  paralysis  of  the  soft 
palate  exists,  fluids  should  not  be  given  except  by  a  nasal 
or  stomach-tube.  Solids  or  semisolids  are  less  dangerous, 
as  the  muscular  action  of  the  cheeks  and  the  tongue  passes 
the  bolus  to  the  back  of  the  throat. 

ARTIFICIAL  RESPIRATION 

Artificial  respiration  is  necessary  when,  for  any  cause, 
the  mechanical  act  of  respiration  ceases  while  life  is  not  de- 
stroyed. Arrested  respiration  produces  the  condition 
known  as  asphyxia,  of  which  the  accompanying  symptoms 
are  lividity,  cyanosis,  and  loss  of  consciousness. 

Causes. — Asphyxia  may  result  from  the  following  causes : 
Mechanical  obstruction,  as  in  drowning  or  edema  of  the 
lungs,  where  the  lungs  are  filled  with  water;  the  lodging 
of  a  foreign  body  in  the  trachea;  edema  of  the  glottis; 
inflammation  or  morbid  growths  of  the  larynx;  pressure 
of  a  tumor  on  the  trachea  or  bronchi ;  a  foreign  body,  such 
as  a  bone,  in  the  esophagus,  pressing  forcibly  on  the 
trachea. 

Convulsive  spasm,  as  in  whooping-cough  or  croup. 

Paralysis  involving  the  muscles  of  respiration,  as  in 
shock  from  lightning  or  electricity,  and  in  injuries  to  the 
upper  part  of  the  spinal  column. 

The  inhalation  of  poisonous  gases. 

The  administration  of  a  general  anesthetic,  especially 
ether. 

In  the  new-born,  from  failure  of  the  lungs  to  expand. 


ARTIFICIAL   RESPIRATION  691 

Where  it  is  possible  to  remove  the  obstruction,  this  is 
obviously  the  first  step  in  the  treatment  of  asphyxia. 
In  any  other  case  artificial  respiration  should  be  begun 
without  a  moment's  delay. 

Where  there  are  fluids  to  be  expelled  from  the  lungs  and 
bronchi,  the  patient  is  placed  on  his  face,  the  head  hanging 
so  that  the  mouth  is  lower  than  the  trunk.  In  other 
circumstances  he  lies  on  his  back,  a  thick  pad  under  the 
shoulders,  and  the  head  thrown  back  lower  than  the  chest. 
In  this  position  the  throat  is  extended  and  the  muscles 
of  the  chest-wall  are  allowed  free  play.  The  tongue  is 
grasped  with  a  handkerchief  or  by  a  pair  of  forceps,  and 
pulled  forward  and  to  one  side,  to  prevent  its  falling  back 
and  mechanically  closing  the  larynx;  a  small  object  is 
placed  between  the  teeth,  to  keep  the  mouth  open.  In 
case  of  vomiting  the  head  should  be  kept  turned  to  one 
side.  The  clothes  are  loosened  round  the  throat,  chest, 
and  abdomen.  Any  collection  of  mucus  in  the  nose  or 
throat  must  be  quickly  wiped  away. 

There  are  several  methods  of  giving  artificial  respiration, 
of  which  the  most  commonly  employed  are  known  as  the 
Sylvester  method  and  the  Marshall  Hall  method. 

The  Sylvester  Method. — The  patient  is  placed  on  his 
back,  as  just  described,  the  tongue  drawn  out  and  to  one 
side.  Seizing  the  arms  just  above  the  elbow,  they  are 
slowly  abducted,  extended  at  right  angles  to  the  body,  and 
brought  together  above  and  behind  the  head.  By  these 
movements  the  chest-wall  is  slowly  expanded,  as  in  the 
natural  act  of  inspiration.  The  throat  being  extended  and 
the  tongue  drawn  out,  the  air-passages  are  held  open. 
The  arms  are  held  together  above  the  head  for  three  or 
four  seconds.  The  movements  are  then  slowly  reversed, 
and  the  arms  pressed  forcibly  against  the  sides  of  the  chest 
for  about  three  seconds,  causing  the  act  of  expiration. 
The  movements  are  continued  rhythmically.  They  must 
not  be  hurried:  12  or  14  times  a  minute,  somewhat  lower 
than  the  normal  respiration,  is  sufficient. 

The  Marshall  Hall  Method. — The  patient  is  laid  on  his 
side,  a  thick  roll  of  blankets  or  pillows  under  the  chest, 
and  the  arms  placed  above  the  head.  The  head  is  low,  the 


692        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 

throat  extended,  and  tongue  drawn  out,  as  in  the  Sylvester 
method.  The  patient  is  turned  alternately  on  his  face,  to 
compress  the  chest  (expiration),  and  on  his  back,  to  allow 


Fig.    210. — Artificial    respiration:    first    movement,    inspiration 
(Murray). 

the  chest  to  expand  (inspiration).  While  on  his  face,  ex- 
piration is  further  aided  by  pressure  on  the  ribs  from 
behind.  Again,  the  movements  must  be  continued 
rhythmically,  and  not  more  than  12  to  14  times  a  minute. 


Fig.   211. — Artificial    respiration:    second    movement,   expiration 
(Murray). 

Drowning. — In  asphyxia  caused  by  drowning  the  lungs 
and  air-passages  must  be  freed  from  water.  To  do  this, 
the  patient  must  be  placed  in  such  a  position  that  the  head 


ARTIFICIAL   RESPIRATION 

and  shoulders  hang  low,  when  the  water  will  naturally 
escape  by  the  mouth  and  nose.  A  child  may  be  held  by 
the  legs  head  downward,  or  placed  across  the  knees,  face 
downward,  the  abdomen  over  the  knees,  and  the  head  and 
shoulders  hanging  low.  A  larger  patient  may  be  laid  in  the 
same  way  across  a  table,  a  barrel,  the  seat  of  a  boat,  a 
bale  of  goods,  or  anything  available  that  can  be  rolled  into 
a  bundle  sufficiently  large  so  that  pressure  comes  on  the 
lower  part  of  the  chest  and  the  abdomen,  and  the  head  and 
shoulders  can  hang  down.  The  tongue  is  pulled  out  and 
held  to  one  side.  At  the  same  time  the  ribs  are  pressed  at 
the  sides  and  back  to  help  in  emptying  the  lungs.  Arti- 


Fig.  212. — Expressing  water  from  the  stomach  and  lungs  (Murray). 

ficial  respiration,  as  described  above,  is  then  promptly 
begun.  It  should  be  continued  as  long  as  there  is  any 
sign  of  action  of  the  heart.  Recovery  may  occur  after 
several  hours.  While  artificial  respiration  is  being  carried 
out,  no  time  should  be  lost  in  making  every  effort  to  restore 
the  circulation  and  stimulate  the  heart.  Bystanders  should 
be  directed  to  remove  the  wet  clothing  and  cover  the  body 
with  warm  blankets,  etc.,  and  to  apply  friction,  under 
cover,  to  the  extremities.  Stimulants,  especially  atropin 
(rW  ^°  s'o  grain)  and  strychnin  (^  to  T^  grain),  are  given 
by  hypodermic;  whisky  or  brandy  may  be  given  by  rectum. 
Counterirritants  in  the  shape  of  a  sinapism  or  poultice  may 
be  applied  over  the  heart;  cold  water  may  be  dashed  over 


694        NURSING   IN    ACCIDENTS   AND   EMERGENCIES 

the  chest,  or,  if  available,  a  current  of  electricity  may  be 
applied.  Fluids,  such  as  normal  salt  solution  by  enema  or 
hypodermoclysis,  are  avoided.  On  recovery,  the  usual 
reaction  from  shock  may  be  present,  especially  in  nervous 
patients.  Until  completely  recovered,  patients  should  be 
kept  in  bed  and  quiet. 

Asphyxia  of  the  New-born. — In  the  new-born,  failure 
of  the  lungs  to  expand  may  be  due  to — (1)  Blocking  of  the 
air-passages  with  secretions;  (2)  delayed  reflex  action;  or 
(3)  lack  of  vitality.  In  the  first  two  conditions  the  baby  is 
cyanosed  (blue  asphyxia) ;  in  the  third,  the  skin  and  mucous 
membranes  are  livid  (white  asphyxia),  and  the  baby  shows 
no  sign  of  vitality. 


Fig.  213. — Schultze's method  of  artificial  respiration  (Hirst). 

The  first  step  in  the  treatment  is  to  wipe  the  nose  and 
mouth  free  of  secretion.  If  the  skin  is  cyanosed,  the 
baby  should  be  slapped  smartly  on  the  back,  which  is  often 
sufficient  to  excite  respiration  as  a  reflex  action,  or  the 
ribs  may  be  compressed  several  times  in  succession. 
If  these  means  fail,  two  methods  of  artificial  respiration 
are  usually  employed  in  preference  to  either  described 
above,  although  the  Sylvester  method  is  also  frequently 
used. 

The  Schultze  Method. — The  baby  is  held  at  arm's 
length,  suspended  by  each  axilla,  the  back  turned  toward 
the  operator.  The  hands  of  the  operator  are  held  with  an 
index-finger  in  each  axilla,  the  thumbs  over  the  clavicle, 


ARTIFICIAL   RESPIRATION  695 

and  the  palms  and  remaining  fingers  against  the  back, 
on  either  side  of  the  spine.  In  this  position  he  is  swung 
forward  and  upward,  so  that  the  lower  half  of  the  body  is 
doubled  over  the  upper  and  the  abdomen  compressed 


Fig.   214. — Byrd's  method   of  artificial  respiration:  first  position 
(Dorland1) . 


(Borland). 

against  the  chest.  After  one  or  two  seconds  the  move- 
ment is  reversed.  The  movements  are  repeated  about  14 
to  18  times  a  minute. 

The  Byrd  Method.- — The  baby  is  taken  in  both  hands. 
The  right  is  placed  behind  the  shoulders,  the  thumb  and 


i  'i 

Fig.  215. — Byrd's  method  of  artificial  respiration:  full  inspiration 

(T)r\r\nr\f\\ 


(Dorland). 

index-finger  brought  over  the  clavicles,  on  either  side  the 
neck.  The  left  hand  grasps  the  buttocks.  Between  the 
hands  the  body  is  then  doubled,  using  gentle  force,  and  the 


690        NURSING    IN   ACCIDENTS    AND   EMERGENCIES 

abdomen  compressed  against  the  chest;  by  the  reverse 
movement  the  body  is  extended  until  the  spine  is  arched. 
The  movements  must  be  done  slowly,  and  repeated  about 
14  to  18  times  a  minute. 

In  the  condition  of  white  asphyxia  the  baby  is  usually 
placed  in  a  hot  bath  (100°  F.,  increased  to  105°  F.). 
Under  these  circumstances  the  sides  of  the  chest  may  be 
taken  between  the  hands,  and  gentle,  forcible  pressure 
made  and  relaxed  from  14  to  18  times  a  minute.  The 
chin  must  be  kept  up  and  forward,  and  the  tongue  drawn 
out  and  to  the  side. 


Fig.  216.- 


-Byrd's  method  of  artificial  respiration:    full  expiration 
(Borland). 


The  gums  and  lips  at  the  same  time  may  be  rubbed  with 
brandy  and  water. 

Examination  of  a  new-born  infant  may  show  that  the 
chest-wall  has  expanded  unequally,  although  the  baby  may 
appear  to  be  breathing  comfortably.  In  this  circumstance 
also  artificial  respiration  must  be  practised  until  the  con- 
dition is  rectified. 


FAINTING  OR  SYNCOPE 

Fainting  is  a  condition  involving  temporary  loss  of 
consciousness,  either  partial  or  complete,  the  result  of  a 
change  in  the  force  of  the  action  of  the  heart. 

The  heart's  action  is  controlled  both  by  the  central 
nervous  system  and  by  the  sympathetic  nervous  system. 
Conditions  that  affect  either  system  may  cause  a  temporary 
suspension  of  the  activity  of  the  heart  and  produce  syn- 


CEREBRAL   CONCUSSION,  HEAT-STROKE,  STARVATION    697 

cope.  Causes  affecting  the  central  nervous  system  are 
anemia  of  the  brain,  as  in  cases  of  hemorrhage,  an  insuffi- 
cient supply  of  oxygen  in  the  atmosphere,  exposure  to 
heat,  and  poisoning  by  certain  drugs,  especially  the  car- 
diac depressants.  Causes  acting  through  the  sympathetic 
nervous  system  may  be  emotional,  such  as  fear,  joy,  appre- 
hension, an  offensive  sight,  or  poisoning  by  a  drug  that 
acts  on  the  inhibitory  nerves  of  the  heart  (sympathetic), 
such  as  digitalis. 

Premonitory  symptoms  of  an  attack  are:  a  sensation 
of  weakness,  giddiness,  and  inability  to  stand;  ringing  in 
the  ears;  the  sense  of  blindness;  a  clammy  skin  or  profuse 
sweating.  During  the  attack  the  patient  loses  conscious- 
ness and  sinks  to  the  ground;  the  muscles  are  completely 
relaxed,  the  pulse  is  small  and  weak,  the  breathing  shallow, 
the  face  and  lips  pale,  and  the  eyes  closed. 

The  treatment  is  to  lay  the  patient  flat,  with  the  head 
and  shoulders  lower  than  the  rest  of  the  body,  to  loosen 
the  clothing  about  the  throat,  chest,  and  waist,  and  admit 
fresh  air  freely.  When  consciousness  is  regained,  water  or 
aromatic  spirits  of  ammonia  (60  minims  in  |  ounce  of 
water)  should  be  given.  If  the  attack  is  prolonged,  the 
respiration  may  be  stimulated  by  smelling  salts  or  burning 
feathers,  the  hands  and  face  sponged  with  cold  water  and 
briskly  rubbed,  or  reflex  action  may  be  encouraged  by 
slapping  the  chest  smartly  above  the  heart. 

After  an  attack  of  syncope  the  patient  should  lie  still 
and  not  attempt  to  sit  up  or  walk  until  fully  recovered,  or 
the  attack  may  recur. 

CEREBRAL  CONCUSSION,  HEAT-STROKE,   STARVATION 

Concussion,  or  cerebral  shock,  is  the  effect  on  the  brain 
of  a  fall  or  direct  violence,  where  there  is  no  lesion  of  the 
brain  substance.  The  function  of  the  brain  is  temporarily 
arrested  or  stunned. 

Usually  there  is  a  short  interval  of  insensibility,  with 
symptoms  of  syncope,  pallor,  and  small,  feeble  pulse; 
the  respirations  are  quiet,  whereas,  in  conditions  of  brain 
injury,  stertorous  breathing  is  an  early  symptom;  as  con- 
sciousness returns  there  are  sensations  of  dizziness,  head- 


698        NURSING   IN   ACCIDENTS  AND   EMERGENCIES 

ache,  and  nausea;  vomiting  is  frequently  present,  and  the 
mental  faculties  may  be  confused.  After  resting,  the 
symptoms  may  pass  away  entirely. 

In  more  severe  cases  a  semicomatose  condition  persists 
for  some  days.  The  patient  lies  with  eyes  closed,  indiffer- 
ent to  all  that  passes,  but  can  be  roused  by  talking  or 
shouting.  The  mind  is  generally  clear,  but  not  infrequently 
there  is  no  memory  for  events  immediately  preceding  the 
accident. 

Rest  in  bed  with  the  light  shaded,  the  administration 
of  a  purgative,  and  a  liquid  diet  until  the  symptoms  disap- 
pear are  usually  all  the  treatment  necessary.  Persistent 
headache  is  relieved  by  the  application  of  an  ice-bag. 

Heat-stroke,  thermic  fever,  insolation,  sunstroke,  are 
names  used  to  describe  a  condition  resulting  from  undue 
exposure  to  heat  or  to  the  direct  rays  of  the  sun. 

There  are  two  distinct  varieties,  heat  exhaustion  or 
prostration  and  heat-stroke  proper. 

Heat  Exhaustion. — The  symptoms  are  exhaustion, 
sensation  of  great  weakness,  clammy  skin,  cold  extremi- 
ties, small,  feeble  pulse,  and  shallow  respirations.  As 
a  rule,  consciousness  is  not  lost,  but  syncope  may  occur. 

The  patient  must  be  moved  out  of  the  sun  and  placed 
in  the  recumbent  position,  with  the  head  low;  the  clothing 
must  be  loosened,  fresh  air  admitted,  and  external  warmth, 
such  as  blankets  and  hot-water  bags,  applied;  cardiac 
stimulants,  especially  aromatic  spirits  of  ammonia  (60 
minims)  or  strychnin  (3^  to  y-  grain),  are  given,  and  water 
or  hot  tea  or  coffee  to  drink.  The  patient  should  rest  until 
entirely  recovered.  As  a  rule,  there  are  no  after-effects. 
For  some  days  the  action  of  the  heart  may  remain  weak. 
Usually  rest  and  avoidance  of  exertion  is  all  the  treat- 
ment necessary. 

Heat-stroke  is  a  condition  of  great  gravity,  and  if  un- 
relieved is  quickly  fatal.  Some  cases  terminate  fatally 
in  less  than  an  hour.  The  usual  patients  are  men  that 
have  been  doing  hard  physical  labor  in  a  high  temperature. 
There  may  be  premonitory  symptoms  of  vomiting  and 
acute  headache.  The  patient  rapidly  becomes  unconscious, 
the  surface  of  the  skin  is  deeply  flushed  and  cyanosed,  the 


CEREBRAL   CONCUSSION,  HEAT-STROKE,  STARVATION   699 

eyes  bloodshot,  the  pupils  contracted,  perspiration  is 
arrested,  the  temperature  rises  rapidly  to  from  105°  to 
110°  F.,  the  pulse  is  rapid  and  small,  the  respirations  either 
stertorous  or  rapid  and  shallow.  Convulsions  or  delir- 
ium may  be  present. 

In  the  treatment  not  a  moment  must  be  lost.  The 
patient  is  moved  out  of  the  sun,  the  clothes  stripped,  and 
cold  in  the  most  immediately  available  form  applied  to 
the  whole  body.  The  water-hose,  cold  bath,  ice  rub,  or 
the  cold  pack,  frequently  changed,  are  the  usual  means 
employed;  plenty  of  fresh  air  must  be  available.  Cold 
rectal  irrigation  is  also  frequently  used.  The  treatment 
must  be  carried  out  constantly  until  the  temperature  drops 
and  the  patient  perspires  naturally.  The  pulse  must  be 
closely  watched  and  cardiac  stimulants  given  if  necessary. 
In  patients  of  robust  appearance,  venesection  (£  to  1  pint), 
followed  by  infusion  of  hot  normal  salt  solution,  is  some- 
times prescribed. 

On  recovery,  the  patient  is  put  to  bed  in  a  darkened 
room  with  plenty  of  fresh  air.  A  purge  is  given  and  the 
action  of  the  skin  and  kidneys  encouraged  by  drinking 
water  freely.  An  ice-bag  should  be  kept  on  the  head. 
In  severe  cases  convalescence  is  slow  and  is  treated  with 
prolonged  rest  and  quiet,  and  careful  attention  to  diet  and 
to  the  condition  of  the  bowels  and  kidneys.  Exposure  to 
the  sun  must  be  avoided. 

Where  prompt  treatment  is  available,  recovery  may  be 
looked  for.  After-effects  frequently  met  with  are  impair- 
ment of  the  memory,  failure  of  mental  power,  a  tendency 
to  severe  headache,  and  inability  to  bear  exposure  to  heat 
or  to  the  direct  rays  of  the  sun.  One  attack  predisposes  to 
another. 

In  tropical  countries  exposure  to  the  sun  has  been  known 
to  cause  acute  meningitis. 

In  Animals. — It  is  humane  to  remember  that  animals, 
particularly  horses  and  dogs,  leading  the  artificial  life  of 
the  cities,  are  also  liable  to  heat-stroke.  In  dogs  it  is 
often  shown  by  an  attack  of  wildness  and  extreme  excit- 
ability, ending  in  convulsive  seizures,  from  which  they 
usually  recover. 


700        NURSING    IN   ACCIDENTS   AND   EMERGENCIES 

The  condition  may  often  be  averted  by  keeping  animals 
out  of  the  sun  and  supplying  them  with  sufficient  drinking- 
water.  Horses,  if  obliged  to  work,  should  be  kept  as  much 
as  possible  in  the  shade,  should  not  be  hurried,  and  should 
have  their  mouths  and  nostrils  frequently  sponged  with 
cold  water. 

Starvation  as  an  emergency  is  usually  complicated  by 
exposure.  The  condition  is  one  of  general  collapse, 
frequently  accompanied  by  coma.  The  patient  should  be 
put  to  bed,  external  warmth  applied,  and  the  extremities 
briskly  rubbed.  Food  in  fluid  form  is  given  in  very  small 
quantities,  gradually  increased  at  regular  intervals. 
Hot  normal  salt  solution  is  given  by  rectum  or  by  hypo- 
dermoclysis.  Cardiac  stimulants  are  generally  given  by 
hypodermic  injection.  Reflex  vomiting  may  occur  as  the 
nerve-centers  react  to  treatment,  and  it  may  be  necessary 
for  a  time  to  give  the  nourishment  by  rectum.  Con- 
valescence is  usually  rapid  unless  complicated  by  the 
consequences  of  exposure,  such  as  pneumonia,  inflamma- 
tory rheumatism,  etc. 


SYMPTOMS  AND  CONDITIONS  FREQUENTLY  MET 

WITH 

Pain — Delirium — Delusion — I  llusion — Hallucination — Coma — 
Coma  Vigil — Insomnia — Paralysis — Hemiplegia — Paraplegia — 
Edema — Dropsy — Vomiting — Hiccup — Constipation  — -  Diarrhea — 
Rigor — Sweating — Sudamina — Fever:  Causes;  Varieties;  Course; 
Incubation — Eruptions:  Some  Other  Skin  Eruptions. 

PAIN 

PAIN  is  a  subjective  symptom  (p.  220),  and  as  such 
should  be  described  in  the  words  of  the  patient.  At  the 
same  time  the  condition  is  commonly  accompanied  by 
certain  objective  symptoms,  which  must  be  carefully  noted. 

The  chief  causes  of  pain  are  inflammation,  injury, 
pressure,  as  from  a  tumor,  a  collection  of  fluid  in  a  circum- 
scribed area,  or  an  obstructive  body,  such  as  gall-stone; 
and  acute  irritation  of  a  nerve,  as  in  facial  neuralgia. 

The  subjective  symptoms  of  pain  include  the  character 
of  the  pain,  its  location,  and  its  duration. 

Varieties. — Pain  is  described  as  dull  or  sharp.  A  dull 
pain  may  be  aching  or  boring;  a  sharp  pain  may  be  cutting, 
shooting,  throbbing,  or  griping.  A  sharp  shooting  pain  is 
sometimes  described  as  lancinating. 

Throbbing  pain  is  due  to  local  congestion,  and  frequently 
associated  with  the  formation  of  pus.  Boring  pain  is 
usually  caused  by  persistent  pressure,  as  from  a  tumor. 
It  is  a  characteristic  symptom,  for  example,  of  thoracic 
aneurysm. 

Pain  is  always  more  or  less  localized;  in  some  conditions 
it  may  involve  a  very  large  proportion  of  the  body.  Thus 
in  some  infectious  conditions  (smallpox,  influenza,  diph- 
theria) we  have  acute  pain  in  the  back,  lower  extremities, 
and  head.  In  acute  inflammatory  rheumatism  and  in 
pyemia  we  have  pain  attacking  many  of  the  joints  simul- 

701 


702      SYMPTOMS   AND    CONDITIONS    FREQUENTLY    MET 

taneously,  and  disappearing  from  one  part  of  the  body,  to 
reappear  immediately  in  another. 

Pain  may  be  continuous,  intermittent,  or  occur  in  par- 
oxysms. Neuralgic  pain  has  a  tendency  to  recur  in  parox- 
ysms at  regular  intervals. 

The  onset  of  pain  may  be  sudden  or  gradual,  and  it  may 
also  disappear  suddenly  or  gradually.  Sudden  relief  from 
acute  local  pain  usually  suggests  the  removal  of  pressure  or 
of  an  obstruction;  thus  in  the  sudden  relief  of  toothache  we 
have  an  escape  of  fluid  into  the  soft  tissues;  an  abrupt 
cessation  of  pain  in  an  attack  of  renal  or  hepatic  colic  in- 
dicates the  escape  of  an  obstruction  into  a  less  constricted 
passage. 

Objective  symptoms  to  be  noticed  in  reference  to  pain 
are:  Changes  in  the  pulse  or  respiration;  the  existence  of 
swelling,  discoloration,  deformity,  or  local  tenderness; 
the  expression  of  the  face,  whether  drawn  and  pinched,  or 
worn  and  apathetic;  moaning  or  crying;  the  attitude  as- 
sumed, and  whether  pain  appears  to  be  increased  by 
moving  or  touching. 

In  acute  abdominal  pain  the  tendency  is  to  draw  the 
knees  up,  in  order  to  relax  the  abdominal  muscles;  in 
pleurisy  the  patient  lies  on  the  affected  side,  in  order  to 
restrict  the  painful  movement  during  respiration;  in  colicky 
pain  the  body  is  sharply  doubled  to  relieve  the  contractions. 

Remedies  used  for  the  relief  of  pain  are  called  anodynes 
or  analgesics.  They  may  be  systemic,  acting  through  the 
nervous  system,  or  local. 

Of  the  systemic  anodynes,  the  most  important  is  opium, 
especially  its  principal  salt,  morphin.  Others  are  bella- 
donna, cannabis  indica,  hyoscyamus,  antipyrin,  acetanilid, 
phenacetin,  and  many  others. 

Local  anodynes  are  heat,  especially  moist  heat,  cold,  the 
different  forms  of  counterirritation,  and  several  drugs, — 
belladonna,  camphor,  chloroform,  etc., — usually  applied  in 
the  form  of  liniments  or  plasters. 

A  condition  in  which  pain  when  afflicted  is  not  felt  is 
known  as  anesthesia.  Unless  produced  by  the  action  of  a 
general  anesthetic,  it  is  due  to  paralysis  of  the  sensory 
nerves.  It  may  be  strictly  local,  as  in  the  facial  paralysis 


DELIRIUM  703 

often  temporarily  following  a  mastoid  operation,  or  as 
produced  by  a  local  anesthetic;  or  it  may  involve  half  of 
the  whole  body,  as  in  paraplegia. 

Hyperesthesia  is  an  abnormal  sensitiveness  to  touch, 
and  is  most  commonly  found  associated  with  neurasthenia 
or  hysteria.  Absence  of  pain  may  sometimes  be  a  grave 
symptom.  Thus  in  accidents  to  the  spine  no  pain  is  felt 
below  the  seat  of  injury,  owing  to  total  paralysis  caused 
by  pressure  on  the  spinal  cord;  in  a  deep  burn  pain  is 
absent,  owing  to  the  destruction  of  the  nerve-endings;  in 
cases  of  severe  shock,  pain  is  frequently  not  experienced, 
even  in  violent  injuries. 

DELIRIUM 

Delirium  is  an  acute  disorder  of  the  mental  faculties, 
due,  commonly,  to  disease.  Two  types  are  recognized, 
low  muttering  delirium  and  wild  delirium. 

The  low  muttering  delirium  is  characterized  by  dis- 
connected, irrational  speech,  restless  impulses,  and  im- 
paired will  and  motor  power.  Disturbing  dreams  and 
attacks  of  weeping  or  excitement  are  common.  In  mild 
cases  the  delirium  is  intermittent  and  the  patient  can  fre- 
quently be  roused  to  answer  questions  sensibly.  In  more 
severe  cases  the  muttering  is  constant,  the  patient  appears 
insensible  to  his  surroundings,  and  fails  to  show  any  recog- 
nition of  his  friends.  The  stools  and  urine  are  passed 
involuntarily.  Plucking  at  the  bed-clothes,  or  carphology, 
is  a  frequent  symptom.  Low  muttering  delirium  is  com- 
mon in  all  the  acute  infectious  fevers.  In  typhoid  fever 
it  is  to  some  extent  almost  invariably  present.  Where 
restlessness  is  a  feature,  the  patient  continually  tries  to 
get  out  of  bed,  and  not  infrequently  to  escape  by  the 
window. 

Low  muttering  delirium  is  commonly  treated  by  hydro- 
therapeutic  measures,  especially  the  cold  tub-bath  or  the 
wet  pack.  Either  of  these  measures  almost  invariably 
relieves  the  symptoms  for  a  time. 

Wild  delirium  is  a  condition  of  maniacal  excitement. 
It  is  usually  associated  with  toxic  conditions  not  due  to 
bacterial  infection.  The  deliriums  of  uremia,  alcoholism, 


704      SYMPTOMS   AND    CONDITIONS   FREQUENTLY  MET 

and  of  poisoning  by  a  certain  class  of  drugs  are  examples. 
The  drugs  which  induce  delirium  are  known  as  deliriants; 
such  are  belladonna,  stramonium,  hyoscyamus,  and  others. 
Patients  of  alcoholic  habit  frequently  develop  wild  mania 
in  the  course  of  an  acute  infectious  disease.  The  patient 
is  noisy,  violent  in  his  actions,  insensible  to  his  surround- 
ings, and  difficult  to  control.  The  eyes  are  wide  open  and 
staring,  and  usually  dilated;  the  face  is  flushed;  the  speech 
is  incoherent  and  rapid.  The  condition  is  generally  con- 
trolled by  the  use  of  sedatives  or  narcotics,  and  the  patient's 
general  health  is  carefully  supported  by  regular  nourish- 
ment. In  alcoholic  cases  a  certain  amount  of  stimulation 
is  usually  necessary.  The  treatment  includes  the  means 
for  eliminating  or  neutralizing  the  poison.  Enforced 
physical  restraint  may  be  necessary. 

Delirious  patients  require  watching,  even  when  the 
symptoms  seem  mild.  The  character  of  the  delirium  may 
change  abruptly,  and  the  patient  escape  by  the  window  or 
do  himself  other  injury.  In  wild  delirium  a  homicidal 
mania  may  develop.  The  means  for  quick  restraint 
should  always  be  at  hand.  The  fact  should  be  borne  in 
mind  that  delirium  may  develop  suddenly  in  any  condi- 
tion associated  with  high  temperature,  and  such  patients 
should  constantly  be  under  close  supervision. 

Delirium  due  to  great  exhaustion  is  frequently  associated 
with  the  end  of  a  long  illness  or  conditions  of  low  vitality, 
such  as  following  shock  or  profuse  hemorrhage.  The  chief 
treatment  is  in  the  support  of  the  patient's  strength  by 
regular  nourishment,  stimulation,  hypodermoclysis,  or  in- 
travenous infusion  of  normal  salt  solution,  and  so  forth. 

The  wild  delirium  associated  with  acute  alcoholism  is 
known  as  delirium  tremens,  from  the  tremors  (subsultus) 
which  characterize  the  condition. 

DELUSION,  ILLUSION,  HALLUCINATION 

Delusion  is  the  persistent  possession,  by  the  mind,  of 
a  false  belief,  sufficiently  strong  to  influence  the  actions;  for 
example,  the  fixed  conviction  that  the  life  is  threatened. 

Illusion  is  a  false  conception  concerning  some  actual 


COMA  705 

material  object;  for  example,  the  mistaking  of  a  piece  of 
furniture  for  a  wild  beast. 

Hallucination  is  a  perception  of  objects  or  sounds  that 
have  no  demonstrable  existence;  for  example,  the  hearing 
of  voices  or  the  seeing  of  imaginary  persons  or  animals. 

COMA 

Coma  is  a  condition  of  complete  unconsciousness. 
The  appearance  is  that  of  deep  sleep;  in  certain  conditions 
it  may  be  accompanied  by  delirium. 

Coma  may  occur  in  any  condition  associated  with  pro- 
found exhaustion,  such  as  the  end  of  a  long  illness,  severe 
shock,  or  following  profuse  hemorrhage;  in  toxic  conditions, 
as  the  infectious  fevers,  uremia,  alcoholism,  and  the  aceto- 
nuria  of  diabetes,  and  in  poisoning  by  many  of  the  func- 
tional poisons.  It  is  a  symptom  in  many  diseases  of  the 
brain,  and  one  of  the  early  evidences  of  brain  pressure.  In 
this  condition  it  is  accompanied  by  changes  in  the  respira- 
tion, most  commonly  stertorous  breathing. 

The  coma  due  to  a  toxin  may  be  relieved  by  means  to 
eliminate  or  neutralize  the  poison.  In  the  coma  due  to 
alcoholism,  opium  poison,  and  like  causes,  efforts  are  made 
to  rouse  the  patient  by  talking,  shouting,  enforced  move- 
ments, cold  affusions,  etc.  Diabetic  coma  is  regarded  as 
a  fatal  condition,  though  the  patient  may  linger  a  few 
days.  Coma  accompanying  a  condition  of  profoundly 
lowered  vitality  is  treated  by  prompt  stimulation,  external 
heat,  infusion  or  hypodermoclysis  of  normal  salt  solution, 
and  other  means  described  under  Shock  or  Collapse. 

In  the  large  majority  of  cases  death  is  preceded  by  a 
period  of  coma  of  short  or  long  duration.  Stimulation 
of  the  vital  centers  by  atropin,  strychnin,  camphor,  etc., 
or  the  injection  of  normal  salt  solution,  may  prolong  the 
condition  and  in  some  cases  induce  a  temporary  return 
of  consciousness.  In  many  conditions  this  form  of  coma 
is  accompanied  by  Cheyne-Stokes'  respiration. 

Coma  vigil  is  the  name  given  to  a  state  of  unconscious- 
ness where  the  eyes,  the  pupils  dilated,  remain  open,  with 
an  intensely  watchful  gaze.  The  condition  may  be  accom- 
panied by  delirium.  It  is  seen  in  conditions  of  extremely 

45 


706 

lowered  vitality,  and  is  always  a  grave  symptom,  general!} 
signifying  approaching  death. 

Other  conditions  of  unconsciousness,  usually  attributed 
to  hysteria  or  disturbed  mental  conditions,  are — trance 
or  simulated  death,  catalepsy,  in  which  the  patient,  ap- 
parently insensible,  will  remain  for  a  long  period  in  any 
fixed  position,  and  ecstasy,  an  exalted  condition  frequently 
accompanied  by  extravagant  movements,  such  as  dancing, 
during  which  the  patient  is  apparently  insensible  to  his 
surroundings. 

INSOMNIA 

Insomnia,  or  inability  to  sleep,  is  a  common  occurrence 
in  most  disturbed  physical  conditions,  and  especially  so  in 
conditions  associated  with  fever,  with  pain,  or  following 
a  severe  physical  or  mental  strain,  such  as  an  accident  or  an 
important  operation.  In  the  acute  fevers  there  is  little 
or  no  natural  sleep  during  the  fastigium,  or  febrile  stage. 
The  return  of  natural  sleep  is  a  favorable  symptom;  it  is 
frequently  a  feature  of  the  crisis. 

Acute  insomnia  in  persons  of  alcoholic  habit  is  generally 
a  preliminary  symptom  of  delirium  tremens,  and  for  this 
reason  is  always  promptly  treated.  In  middle  age  and 
elderly  people,  occurring  especially  after  a  shock  or  a  long 
exhausting  illness,  insomnia  is  not  infrequently  the  first 
sign  of  insanity. 

In  the  acute  fevers,  insomnia,  unless  associated  with 
great  restlessness,  is  not  usually  specially  treated.  A  tepid 
or  hot-water  sponging,  an  ice-bag  to  the  head,  attention  to 
comfort  and  quiet,  will  predispose  to  as  much  sleep  as  is 
possible.  In  these  conditions  patients  are  indifferent  to  jbhe 
passing  of  time,  and  loss  of  sleep  is  rarely  complained  of. 
In  loss  of  sleep  due  directly  to  pain,  anodynes  are  com- 
monly given,  of  which  the  most  potent  is  opium  in  some 
form,  usually  morphin,  given  hypodermically.  Where 
acute  pain  is  not  a  feature,  milder  drugs,  such  as  antipyrin, 
phenacetin,  sulphonal,  veronal,  and  many  others,  should 
always  be  preferred  to  morphin;  they  have  less  constitu- 
tional effect,  and  there  is  not  the  same  risk  of  forming  a 
habit. 


INSOMNIA  707 

In  giving  drugs  to  relieve  incidental  insomnia,  much 
judgment  must  be  exercised  by  those  to  whom  the  giving 
is  intrusted.  Other  means  to  induce  sleep  should  be  tried 
first.  Evening  visitors  and  excitement  should  be  forbidden : 
quiet  occupation  or  reading  aloud  substituted,  and  the 
patient's  attention  diverted  from  his  own  condition; 
his  comfort  should  be  carefully  attended  to,  and  disturbing 
noises  prevented  as  far  as  possible.  A  warm  tub-bath, 
when  practical,  or  a  sponge-bath,  an  alcohol  rub,  a  hot- 
water  bag  to  the  feet  and  cold  applications  to  the  head,  or 
massage  of  the  spine  and  forehead,  may  often  prove  effi- 
cacious. 

If  the  administration  of  the  drug  becomes  necessary,  it 
must  be  given  after  every  other  duty  connected  with  the 
patient  or  the  sick-room  is  finished.  It  seems  hardly  neces- 
sary to  add  that  a  sleeping  patient  must  not  be  roused  for 
a  sleeping  draft;  but  in  intrusting  the  administration  of 
medicines  to  a  pupil,  she  must  at  least  be  carefully  in- 
structed as  to  which  medicine  is  for  hypnotic  purposes, 
and  given  orders  not  to  administer  it  unless  necessary. 

The  giving  of  a  placebo,  in  the  shape  of  a  sugar  capsule 
or  sterile  water  hypodermic,  is  sometimes  resorted  to  when 
other  means  of  breaking  the  patient  of  the  use  of  a  narcotic 
have  failed.  To  decide  upon  doing  so  is  not  the  nurse's 
function.  The  most  difficult  patient  to  break  is  the  one 
whose  insomnia  has  been  the  result  of  pain.  His  dread 
of  its  recurrence  will  often  lead  him  to  feign  pain  in  order 
to  procure  what  will  prevent  its  return. 

A  patient's  own  account  of  his  sleep  should  neither 
be  disregarded  nor  receive  implicit  credence;  nor  should 
his  own  account  ever  be  contradicted  in  a  report  given  in 
the  patient's  hearing.  Great  pains  should  be  taken  to 
measure  both  sleeping  and  waking  intervals  by  the  clock, 
and  to  record  both  accurately  on  the  chart.  Broken  sleep 
is  not  restful.  On  a  report,  for  example,  "  sleep,  four  hours  " 
should  mean  only  four  hours'  consecutive  sleep.  If  the 
four  hours  is  the  total  sum  of  many  short  sleeps,  with  rest- 
less intervals  between,  the  record  chart  should  state  the 
fact  clearly. 

Chronic  insomnia  occurring  in  health  is  one  of  the  most 


708      SYMPTOMS   AND    CONDITIONS   FREQUENTLY   MET 

intractable  of  conditions  to  cure.  It  is  most  commonly 
due  to  mental  conditions,  such  as  brain  fatigue  or  persist- 
ent worry;  it  may  result  from  injudicious  use  of  tea  or  coffee, 
the  alcohol  habit,  deficient  hygiene,  sedentary  habits,  or 
lack  of  outdoor  exercise.  Many  cases  are  referred  directly 
to  eye-strain.  Insomnia  is  a  frequent  accompaniment  to 
habitual  constipation. 

Where  the  cause  is  known,  the  first  step  is  to  remove 
or  alleviate  the  cause.  In  many  cases,  however,  the  habit 
once  formed  tends  to  persist.  The  general  health  should 
receive  close  attention,  and  the  habits  regulated  to  in- 
clude fresh  air  and  a  reasonable  amount  of  exercise. 
Coffee  and  tea  should  be  given  up  or  taken  only  in  the 
early  hours  of  the  day,  and  the  use  of  alcohol  restricted  or 
forbidden.  Frequently,  stopping  all  brain  work,  even 
pleasurable  brain  work,  at  an  early  hour  in  the  afternoon 
has  a  beneficial  result.  The  effect  of  a  light  meal  in  place 
of  the  heavier  dinner  at  night  should  be  tried. 

At  bedtime  means  are  used  which  have  for  their  object 
the  reduction  of  the  blood-supply  in  the  brain.  An 
anemic  brain  will  sleep.  Heat  to  the  extremities  and  cold 
to  the  head  are  the  usual  means.  A  hot  tub-bath  or  hot 
foot-bath,  hot-water  bags  to  the  feet  or  over  the  abdomen, 
with  an  ice-bag  or  bag  of  ice  water  to  the  head,  are  simple 
means.  The  cold  bag  should  be  placed  at  the  back  of  the 
neck  and  side  of  the  head.  A  light  meal,  a  cup  of  warm 
milk,  or  hot  whisky  toddy  may,  in  milder  cases,  be 
sufficient  to  divert  the  blood  from  the  head  to  the  stomach 
and  induce  sleep.  Other  means  are  massage,  either  gen- 
eral or  to  the  spine  and  head,  and  the  wet  pack.  In  very 
overwrought  conditions  the  wet  pack  is  usually  the  best 
immediate  treatment. 

Acute  insomnia  in  health  is  frequently  seen  as  the  result 
of  abnormal  mental  effort  or  acute  business  worry.  The 
best  treatment  is  complete  change  of  scene  and  occupation. 
When  this  is  impossible,  the  amount  of  mental  work 
should  be  reduced  to  a  minimum,  and  the  health  and  habits 
carefully  regulated;  of  the  means  of  immediate  treatment, 
the  wet  pack  is  generally  the  most  beneficial. 

Insomnia  in  a  child  is  usually  due  to  a  mental  condition, 


PARALYSIS  709 

and  always  an  important  symptom.  Women  are  more 
prone  to  insomnia  than  men.  Aged  people  are  wakeful, 
but,  as  a  rule,  they  do  not  suffer  from  the  effects  of  loss 
of  sleep. 

When  it  becomes  necessary  to  employ  drugs  for  insom- 
nia, the  ease  with  which  the  narcotic  habit  is  formed  should 
never  be  lost  sight  of.  It  should  never  be  begun  without 
medical  advice  nor  continued  away  from  medical  super- 
vision. The  excitable  temperament  most  liable  to  in- 
somnia is  liable  to  be  deficient  in  self-control. 

PARALYSIS 

By  paralysis  we  usually  understand  a  loss  of  the  power 
of  movement,  usually  also  accompanied  by  loss  of  sensa- 
tion, not  due  to  local  impairment,  but  to  disturbance  of 
the  nerve-centers  that  govern  movement.  This  disturb- 
ance may  be  due  to  disease,  to  direct  injury,  or  to  pressure. 

With  our  complex  nervous  system,  the  varieties  of  par- 
alysis are  numerous.  We  find  a  special  lesion  in  some 
special  part  of  the  brain  or  spinal  cord,  followed  by  special 
symptoms  of  impairment  of  power  and  nutrition  in  special 
groups  of  muscles.  In  many  cases  the  group  of  symptoms 
are  classed  as  a  disease  and  known  by  the  name  of  the 
observer  or  authority  who  originally  called  attention  to 
the  special  manifestations.  A  large  number  of  these 
forms  of  paralysis  are  the  result  of  changes  due  to  incurable 
disease  and  develop  very  slowly. 

Paralysis  may  affect  one  entire  side  of  the  body  (hemi- 
plegia), or  the  whole  body  below  a  certain  point  in  the 
spine  (paraplegia);  paralysis  may  also  be  strictly  local, 
affecting  one  limb  or  a  special  group  of  muscles,  as  in  facial 
paralysis. 

Hemiplegia. — In  hemiplegia  the  lesion  is  in  the  brain,  in 
paraplegia  the  spinal  cord  is  the  seat  of  injury. 

Hemiplegia  is  most  commonly  the  result  of  an  apoplexy  or 
cerebral  hemorrhage,  and  begins  with  an  acute  condition 
of  unconsciousness,  stertorous  breathing,  etc. ;  it  may  also 
result  from  disease  of  the  brain  tissue,  embolism,  or  press- 
ure on  the  brain  from  a  tumor  or  depressed  fracture  of 
the  skull  (p.  638). 


710      SYMPTOMS   AND    CONDITIONS   FREQUENTLY   MET 

In  a  typical  case  of  apoplexy,  the  patient  falls  to  the 
ground  in  an  unconscious  condition,  the  respirations  are 
stertorous,  the  pulse  full  and  slow,  the  face  congested  and 
somewhat  cyanosed;  the  eyes  are  half  open  and  the  pupils 
do  not  react  to  light.  There  may  be  twitching  of  the 
muscles  or  epileptiform  convulsions.  The  temperature  is 
first  subnormal  and  later  usually  raised. 

As  the  acute  symptoms  subside,  the  patient  is  found  to 
have  no  power  on  one  side  of  his  body.  In  some  conditions 
sensation  is  not  lost,  in  others  there  is  either  complete  or 
partial  anesthesia.  With  some  rare  exceptions  the  paraly- 
sis is  on  the  opposite  side  to  the  injury,  owing  to  the  fact 
that  the  nerves  cross  at  the  part  of  the  brain  known  as 
the  pons,  so  that  the  nerve-center  that  governs  the  move- 
ment of  a  muscle  is  situated  in  a  portion  of  the  brain  on 
the  opposite  side  from  the  muscle  it  governs.  In  hemi- 
plegia  of  the  right  side  of  the  body  the  organ  of  speech  is 
usually  affected. 

Recovery  in  hemiplegia  follows  removal  of  pressure,  in 
some  conditions  from  surgical  intervention,  usually  from 
gradual  absorption  of  the  blood-clot.  Where  the  hemor- 
rhage has  been  due  to  arterial  degeneration,  apoplexy  is 
very  liable  to  recur,  and  eventually  to  prove  fatal.  After 
several  attacks,  or  where  the  injury  has  been  extensive, 
hemiplegia  usually  results  in  impairment  of  the  mental 
faculties :  loss  of  memory,  mental  sluggishness,  and  aphasia 
are  common  effects. 

Paraplegia,  or  paralysis  of  the  lower  extremities  and 
lower  part  of  the  trunk,  is  the  result  of  injury  or  disease 
involving  the  spinal  cord.  Occurring  suddenly,  the  most 
frequent  cause  is  fracture  or  dislocation  of  the  spine  (p. 
643).  The  motor  and  the  sensory  nerves  are  both  paral- 
yzed, and  the  bladder  and  rectum  involved.  Unless  the 
injury  has  also  caused  concussion  or  other  brain  condition, 
the  mind  is  clear. 

Paralysis  occurs  below  the  seat  of  lesion;  when  this  is 
so  high  as  to  involve  the  muscles  of  respiration,  death 
occurs  from  asphyxia.  Cases  of  mild  injury  recover  com- 
pletely, others  live  years  with  the  body  paralyzed  from 
the  waist  downward.  Severe  injuries  are  usually  fatal:  the 


EDEMA  711 

patient  lingers  a  few  months  and  finally  dies  of  exhaus- 
tion or  one  or  other  of  the  complications  of  the  condi- 
tion. 

Special  forms  of  paralysis  frequently  met  with  are  in- 
fant's paralysis  and  facial  paralysis.  Infant's  paralysis, 
acute  anterior  poliomyelitis,  affects  certain  groups  of  mus- 
cles in  the  lower  extremities,  and  is  due  to  alterations 
in  a  minute  portion  of  the  spinal  cord.  Facial  paralysis 
is  an  affection  of  the  nerve-endings,  generally  due  to  in- 
flammation of  the  periphery,  sometimes  from  such  a 
trifling  cause  as  sleeping  in  a  draught.  The  condition  may 
also  be  the  result  of  pressure  on  some  part  of  the  nerve, 
from  which  reason  it  is  sometimes  present  as  a  temporary 
condition  after  operations  on  the  mastoid. 

EDEMA 

Edema  is  a  swelling  due  to  the  accumulation  of  fluid  in 
the  tissues.  It  may  be  caused  by  local  inflammation,  as 
in  contused  wounds.  When  it  is  a  simple  infiltration  of 
fluid  from  the  blood-vessels,  unattended  by  inflammation, 
it  is  known  as  dropsy. 

Dropsy. — The  characteristic  appearance  of  dropsy  is  a 
puffy,  colorless  swelling  which  pits  on  pressure.  That  is 
to  say,  if  the  finger  is  pressed  over  the  surface  a  depression 
is  made  which  persists  for  an  appreciable  time.  The 
skin  has  a  waxy  hue,  and  when  the  dropsy  is  excessive,  a 
stretched,  shiny  appearance. 

The  fluid  in  dropsy  is  derived  directly  from  the  circula- 
tion. It  may  be  forced  out  through  the  walls  of  the  capil- 
laries by  the  pressure  of  a  venous  obstruction,  or  may 
result  from  changes  in  the  capillary  vessels  themselves,  or 
from  alteration  in  the  composition  of  the  blood.  The  most 
common  conditions  associated  with  dropsy  are  nephritis, 
chronic  valvular  heart  disease,  and  anemia.  A  local  dropsy, 
i.  c.,  confined  to  one  limb,  is  most  commonly  the  result  of 
a  thrombus.  It  may  also  be  produced  by  any  condition 
causing  pressure,  such  as  a  tumor,  or  prolonged  mechanical 
constriction,  as  in  tight  bandaging. 

The  dropsy  in  nephritis  first  appears  about  the  eyes,  and 
is  most  noticeable  on  first  waking,  and  on  the  side  on  which 


712      SYMPTOMS   AND   CONDITIONS   FREQUENTLY   MET 

the  patient  has  been  lying.  In  heart  disease  the  dropsy 
first  appears  about  the  feet  and  ankles,  and  gradually 
ascends.  The  dropsy  of  anemia  is  usually  confined  to  a 
puffiness  of  the  feet  and  ankles,  observed  at  the  end  of  the 
day  and  improved  by  the  night's  rest. 

The  term  dropsy  is  also  used  for  accumulations  of  fluid 
in  the  cavities  of  the  body,  as,  for  example,  the  pericar- 
dium or  the  abdomen.  The  fluid  is  confined  to  the  cavity 
and  does  not  infiltrate  the  tissues  in  the  vicinity.  Fluid 
in  the  abdomen  is  called  ascites;  a  condition  of  general 
dropsy  is  called  anasarca. 

The  condition  of  dropsy  is  treated  principally  through 
the  underlying  cause  of  the  dropsy.  Active  elimination 
by  the  bowels  and  kidneys,  and,  where  the  kidneys  are  im- 
paired, increased  elimination  by  the  skin  are  the  principal 
points  of  general  treatment.  In  conditions  of  extensive 
dropsy  saline  purgatives  are  frequently  ordered  in  strongly 
concentrated  solutions.  As  a  rule,  fluids  are  restricted  in 
the  diet,  but  this  depends  on  the  underlying  cause.  (See 
Salt-free  Diet,  Chap.  XXIII.) 

For  the  local  treatment  of  dropsy,  see  Paracentesis, 
p.  532. 

Where  drugs  with  accumulative  properties  are  being 
taken  by  dropsical  patients,  it  should  be  borne  in  mind  that 
a  sudden  withdrawal  of  the  fluid  may  be  followed  by 
symptoms  of  overdose  of  such  drugs  (p.  344).  The  drug, 
to  a  large  extent,  it  is  considered,  has  been  held  in  suspen- 
sion in  the  excessive  fluid,  and  becomes  suddenly  set  free 
in  the  system.  This  is  especially  the  case  with  digitalis, 
which,  both  as  a  heart  tonic  and  as  a  diuretic,  is  largely 
used  in  the  treatment  of  heart  disease  and  nephritis. 

VOMITING  OR  EMESIS 

This  is  a  forcible  ejection  of  the  contents  of  the  stomach. 

The  causes  of  vomiting  may  be  local  or  remote.  Local 
causes  are  those  that  arise  from  disturbance  of  the  function 
of  the  stomach.  The  most  common  are  indigestion, 
catarrh  or  disease  of  the  stomach,  the  action  of  certain 
irritants,  such  as  mustard  or  zinc,  known  as  emetics;  the 


VOMITING   OR   EMESIS  713 

action  of  corrosive  and  irritant  poisons,  and  obstruction 
at  some  part  of  the  alimentary  tract. 

Remote  causes  are  those  that  produce  vomiting  by 
irritation,  direct  or  reflex,  of  the  central  nervous  system. 
Vomiting  due  to  nerve  irritation  is  described  as  central 
vomiting.  Common  causes  of  central  vomiting  are:  Dis- 
ease of  the  brain,  pressure  on  the  brain  from  a  tumor  or 
injury,  the  presence  of  toxins  in  the  blood,  as  in  uremia, 
the  invasion  of  the  system  by  an  acute  infection,  the  ac- 
tion of  certain  drugs,  such  as  apomorphin  or  ipecacuanha, 
known  as  central  emetics;  the  toxic  action  of  many  drugs, 
especially  nerve  depressants;  violent  swinging,  as  in  sea- 
sickness, and  reflex  irritation,  as  in  pregnancy,  worms,  etc. 
Reflex  vomiting  may  be  excited  by  tickling  the  back  of  the 
throat  or  by  strong  unpleasant  odors  and  tastes.  Central 
vomiting  occurring  in  conditions  of  shock  shows  a  return 
of  vitality  in  the  nerve-center,  and  is  considered  a  favorable 
sign. 

Regurgitation  is  the  simplest  form  of  vomiting.  It 
consists  in  the  rejection  of  some  of  the  contents  of  the 
stomach  before  digestion  has  taken  place.  It  occurs  com- 
monly in  infants,  from  too  rapid  feeding.  Occurring  as  a 
constant  symptom  after  small  quantities  only  have  been 
taken,  it  is  frequently  caused  by  stricture  of  the  esophagus. 
The  appearance  and  odor  of  regurgitated  food  are  not 
changed. 

An  attack  of  vomiting  is  usually  preceded  by  headache, 
nausea,  and  local  discomfort,  either  pain  or  distention,  and 
accompanied  by  retching  and  eructation  of  gas.  If  the 
stomach  is  loaded,  the  contents  are  vomited  in  a  partially 
digested  condition.  If  the  stomach  is  empty,  as  after  a 
previous  attack  of  vomiting,  the  vomitus  is  usually  small 
in  quantity,  greenish  yellow,  viscid,  and  with  a  bitter 
taste,  owing  to  the  presence  of  bile.  This  is  the  ordinary 
attack  of  vomiting,  due  to  a  large  variety  of  causes — 
gastric  disturbances,  the  so-called  bilious  attack,  sea-sick- 
ness, intestinal  obstruction,  the  after-effects  of  an  anes- 
thetic, etc.  The  attack  is  followed  by  a  sensation  of  relief 
and  relaxation. 

Treatment. — If  a  patient  is  unconscious,  it  is  important 


714      SYMPTOMS   AND    CONDITIONS   FREQUENTLY   MET 

to  keep  the  head  turned  to  one  side,  so  that  the  vomitus 
does  not  enter  the  larynx.  A  patient  in  an  extreme  con- 
dition of  exhaustion  should  not  be  allowed  to  sit  up  or 
raise  the  head;  the  vomitus  should  be  received  on  a  towel 
or  in  a  shallow  vessel. 

Persistent  vomiting  is  difficult  to  control.  All  food 
should  be  withheld,  the  recumbent  position  maintained, 
and  bright  light  or  moving  objects  excluded.  Counter- 
irritants,  such  as  a  mustard  plaster,  hot  fomentations,  or  a 
small  blister  over  the  stomach,  together  with  an  ice-bag  to 
the  head,  may  have  the  desired  effect;  or  an  ice-bag  may 
be  applied  over  the  stomach.  In  many  cases  lavage  gives 
relief.  The  lavage  may  be  of  plain  warm  water,  or  contain 
bicarbonate  of  soda,  to  counteract  the  acidity  of  the 
stomach.  The  drinking  of  one  or  two  pints  of  warm  water 
will  usually  act  as  lavage  without  the  necessity  of  passing 
the  stomach-tube.  In  some  cases  the  inhalation  of  vinegar 
gives  relief.  As  a  rule,  the  head  should  be  kept  low;  in 
a  few  instances  elevation  of  the  head  of  the  bed  has  had  a 
beneficial  result. 

When  the  cause  is  an  error  in  diet,  lavage,  followed 
by  a  purge,  such  as  castor  oil,  is  often  the  quickest  remedy. 
Where  the  castor  oil  cannot  be  retained,  an  enema  may  be 
given. 

Cracked  ice  to  suck  or  brandy  or  champagne  poured 
over  crushed  ice  and  given  in  sips  are  usually  acceptable 
remedies.  Drugs  frequently  prescribed  for  the  condition 
are  morphin  by  hypodermic  (^  to  ^  grain),  opium,  usually 
by  suppository  (|  to  1  grain),  cocain  (J  grain),  astringents, 
such  as  bismuth  subnitrate  (10  grains),  cerium  oxalate 
(5  grains,  given  dry  on  the  tongue),  hydrochloric  acid 
diluted  (5  to  10  minims),  and  others.  In  some  instances 
obstinate  vomiting  has  been  checked  by  1-minim  doses  of 
carbolic  acid  in  water. 

If  sleep  can  be  induced,  the  attack  frequently  passes  off. 
A  cleansing,  non-nauseating  mouth-wash  should  be  given 
to  rinse  the  mouth. 

Vomiting  occurring  regularly  on  rising  in  the  morning 
is  a  common  symptom  during  the  early  months  of  preg- 
nancy. It  is  unaccompanied  by  nausea,  headache,  or 


HICCUP;  SINGULTUS  715 

retching.  The  vomitus  usually  consists  of  a  little  mucus. 
It  may  often  be  prevented  by  drinking  a  cup  of  tea  before 
moving. 

Mucous  vomiting  on  rising  is  also  a  common  symptom 
in  chronic  alcoholic  gastritis. 

For  abnormal  constituents  in  the  vomitus,  see  Chap. 
VII. 

HICCUP;  SINGULTUS 

The  spasmodic  inspirations  known  as  hiccup  are  caused 
by  a  spasm  of  the  diaphragm  accompanied  at  the  same 
time  by  spasm  of  the  glottis. 

In  health  an  attack  of  hiccup  is  the  result  of  minor 
causes,  such  as  slight  gastric  disturbance  from  overacidity, 
from  bolting  the  food,  or  from  energetic  exercise  too  soon 
after  eating.  The  spasms  may  usually  be  overcome  by 
drinking  water,  either  alone  or  with  a  little  sugar  or  bicar- 
bonate of  soda,  or  by  holding  the  breath  and  so  keeping 
the  diaphragm  and  glottis  immovable  for  a  time. 

Attacks  of  hiccup  occurring  in  the  course  of  disease  are 
usually  significant  and  often  difficult  to  treat.  When 
associated  with  conditions  of  shock  or  collapse,  hiccup  is 
a  symptom  of  serious  exhaustion.  In  certain  conditions 
attacks  of  hiccup  occur  from  reflex  irritation,  these  may 
be:  disease  of  any  part  of  the  alimentary  tract,  pressure 
from  an  aneurysm,  toxic  conditions,  such  as  uremia, 
nervous  disorders,  and  in  conditions  caused  by  pressure  on 
the  brain;  intractable  hiccup  is  not  infrequently  met  with 
in  hysteria. 

The  spasm  if  long  continued  is  extremely  exhausting. 
The  usual  remedies  tried  are  hot  applications  or  counter- 
irritants  applied  over  the  abdomen;  hot  whisky  and  water 
by  mouth;  or  emptying  the  stomach  by  an  emetic  or  lavage. 
Antispasmodics  may  be  effective;  those  usually  prescribed 
are  musk,  Hoffmann's  anodyne,  or  camphor.  Sedatives 
or  narcotics  are  given  to  induce  sleep;  chloroform  inhala- 
tions and  morphin  are  used  in  extreme  cases. 

Frequently  no  treatment  has  any  lasting  effect.  A 
special  movement  in  massage  is  sometimes  followed  by 
good  results.  The  fingers  are  placed  over  the  ribs  on 


716      SYMPTOMS   AND    CONDITIONS   FREQUENTLY   MET 

either  side,  so  that  the  thumbs  meet  at  the  sternum. 
Rhythmic  strokes  are  then  made  with  the  thumbs  from 
the  sternum  downward  and  toward  the  sides,  following  the 
line  of  the  margin  of  the  ribs.  The  treatment  is  chiefly 
valuable  in  hysterical  hiccup. 

CONSTIPATION 

Constipation  is  the  most  common  of  minor  disorders, 
either  in  health  or  disease.  It  may  be  acute  or  chronic. 

Acute  constipation  is  usually  due  to  an  error  in  diet, 
sudden  alteration  in  normal  habits,  or  changes  of  climate. 
It  is  generally  most  quickly  relieved  by  a  dose  of  castor 
oil  or  a  course  of  calomel,  followed  by  sulphate  of  magnesia, 
and  subsequent  attention  to  diet  and  hygiene. 

The  tendency  to  chronic  constipation  is  frequently 
hereditary.  It  may  be  acquired  by  careless  habits,  seden- 
tary occupations,  or  injudicious  diet.  Other  causes  are 
nervous  strain,  overfatigue,  and  the  alcohol  habit. 

Physical  symptoms  that  accompanj^  constipation  are 
headache,  loss  of  appetite,  nervous  irritability,  and  slug- 
gishness of  mind  and  body.  If  allowed  to  become  habitual, 
constipation  is  liable  to  result  in  the  formation  of  hemor- 
rhoids, anal  fissures,  or  in  intestinal  obstruction  from  fecal 
impaction. 

Treatment. — The  condition  should  be  regarded  as  a 
menace  to  health  and  not  allowed  to  continue. 

The  formation  of  a  punctual  habit,  combined  with  tonic 
measures,  such  as  cold  bathing  and  regular  exercise,  will 
frequently,  if  persevered  in,  cure  even  obstinate  cases. 
The  diet  should  be  studied  to  ascertain  the  food  best 
suited  to  the  individual.  Whole  wheat  bread,  oatmeal,  and 
fruit,  particularly  cooked  fruit,  are  mildly  laxative  (Chap. 
XXIII).  The  meals  should  be  taken  at  regular  hours  and 
eating  between  meals  discouraged.  Water,  either  hot  or 
cold,  should  be  drunk  regularly,  and  is  especially  beneficial 
taken  at  bedtime  or  on  first  rising.  A  general  tonic,  such 
as  strychnin,  will  frequently  benefit  the  condition.  Good 
hygiene  and  warm  clothing,  especially  woolen  wear  next 
the  abdomen  and  for  the  feet,  are  important  factors,  and 
particularly  so  with  children. 


DIARRHEA  717 

The  constipation  may  be  largely  due  to  weak  muscular 
action,  and  chiefly  affect  the  lower  bowel.  In  these  cases 
a  simple  enema  or  a  suppository  of  soap  or  glycerin  are 
generally  effective,  and  their  use  for  a  short  time  may  help 
to  establish  a  regular  habit,  especially  in  young  children. 
Their  persistent  use,  however,  has  an  irritating  effect  on  the 
local  mucous  membranes,  and  may  lead  to  the  formation  of 
fissures. 

When  drugs  become  necessary,  they  must  be  used  with 
caution,  and  discontinued  as  soon  as  possible,  as  the  sys- 
tem quickly  comes  to  rely  on  them.  Mild  drugs  are  to  be 
preferred  to  drastic  purges.  Many  cases  of  obstinate 
constipation  are  benefited  by  regular  abdominal  massage. 
It  should  be  given  punctually  at  the  same  hour  every  day. 
When  an  expert  masseuse  is  not  procurable,  the  massage 
may  be  efficiently  performed  with  a  cricket  ball  or  base- 
ball. Placed  over  the  lower  part  of  the  abdomen  to  the 
right,  the  ball  is  carried  slowly  upward,  with  a  rotatory 
movement  of  the  palm  of  the  hand,  then  across  the  abdo- 
men, and,  finally,  down  on  the  left  side,  the  movements 
following  the  direction  of  the  colon.  The  pressure  should 
be  firm  and  even,  but  not  forcible;  the  process  is  usually 
prescribed  for  about  ten  minutes  at  some  time  when  the 
intestines  are  at  rest,  preferably  in  the  morning. 

Constipation  is  a  common  accompaniment  to  many 
diseases,  especially  those  that  interfere  with  the  process 
of  nutrition  or,  from  whatever  cause,  obstruct  the  secre- 
tion of  the  digestive  juices.  It  is  present  in  many  forms 
of  gastritis,  enteritis,  cancer  of  the  stomach  and  intestines, 
jaundice,  and  pancreatic  disease;  in  brain  affections  and 
nervous  conditions;  in  anemia;  and  commonly  in  the  acute 
infectious  fevers.  In  many  of  these  conditions  the  stools 
have  a  characteristic  appearance.  (See  Excreta.) 

DIARRHEA 

By  diarrhea  is  understood  an  abnormal  frequency  of  the 
stools,  with  a  change  in  their  character  and  consistency. 
(See  Excreta.) 

Commonly,  it  is  an  acute  condition  associated  with  in- 
flammation of  some  part  of  the  alimentary  tract.  It  is 


718      SYMPTOMS   AND   CONDITIONS  FREQUENTLY  MET 

symptomatic  of  the  water-borne  infections,  typhoid  fever, 
dysentery,  and  cholera;  it  is  common  in  all  forms  of  gas- 
tritis or  enteritis,  both  acute  and  chronic,  and  may  be 
associated  with  chronic  constipation;  it  accompanies 
acutely  septic  conditions,  and  is  usually  a  symptom  at  the 
close  of  long,  wasting  illnesses;  an  attack  of  diarrhea  is 
also  a  common  accompaniment  of  the  crisis  of  an  infectious 
fever,  such  as  pneumonia. 

The  chronic  form  of  diarrhea  is  commonly  associated 
with  chronic  dyspepsia.  Persons  who  have  suffered 
formerly  from  typhoid  fever  or  dysentery  are  subject  to 
attacks  of  diarrhea  from  trifling  causes  or  in  any  low- 
ered condition  of  health. 

In  nervous  persons  acute  diarrhea  may  result  from  ex- 
citement or  strong  emotion. 

Physical  symptoms  that  accompany  an  acute  attack  of 
diarrhea  are  nausea,  frequently  vomiting,  abdominal 
cramps,  distention,  straining  (tenesmus),  loss  of  appetite, 
and  thirst;  slight  fever  is  not  uncommon;  on  the  other 
hand,  the  temperature  may  be  subnormal. 

The  first  treatment  of  an  acute  attack,  not  associated 
with  a  specific  disease,  is  to  clear  the  alimentary  tract 
by  a  quickly  acting  purgative,  in  order  to  get  rid  of  the 
source  of  irritation.  Castor  oil  is  usually  preferred.  If 
not  effectual  in  two  or  three  hours,  it  is  followed  by  a 
simple  enema.  After  one  or  two  actions  from  the  castor 
oil,  the  diarrhea,  in  favorable  cases,  is  checked;  if  not, 
astringents,  such  as  bismuth  subnitrate  (10  to  20  grains), 
are  usually  ordered,  repeated  every  three  or  four  hours 
until  effectual,  or  opium  in  some  form  may  be  given  (usu- 
ally paregoric,  2  to  4  drams,  or  tincture  of  opium,  10  to 
20  minims;  the  dose  may  be  repeated  once).  Brandy, 
taken  raw  (1  to  2  drams),  has  frequently  a  beneficial  effect. 
Meantime  solid  food  should  not  be  taken.  The  after- 
treatment  of  the  condition  is  chiefly  dietary.  (See  Chap. 
XXIII.)  Fatigue  and  exposure  to  cold,  damp,  or  to 
sudden  changes  of  temperature  must  be  avoided;  fre- 
quently a  short  time  in  bed  is  the  quickest  remedy. 

Diarrhea  in  infants  is  always  an  important  symptom,  and 
may  quickly  become  a  very  serious  condition.  It  may 


RIGOR  719 

result  from  injudicious  feeding,  sour  or  impure  milk,  dirty 
feeding  bottles,  from  cold  or  wet  feet,  or  from  exposure 
to  high  atmospheric  temperature.  It  is  a  common  dis- 
order in  the  summer  months,  particularly  with  bottle-fed 
babies.  It  is  also  the  accompaniment  of  all  acute  infec- 
tions of  the  alimentary  tract  to  which  infants,  especially 
neglected  and  bottle-fed  infants,  are  liable. 

Unless  treatment  is  prompt,  the  condition  may  be  fatal. 
The  first  treatment  aims  at  removing  the  irritating  cause, 
usually  with  a  purge  (unless  in  infectious  conditions,  where 
special  treatment  is  necessary),  following  which  the  treat- 
ment is  largely  dietary  (Chap.  XXIII).  If  the  condition 
persists,  astringent  enteroclysis  is  frequently  ordered. 

RIGOR 

An  acute  paroxysm  of  shivering  is  known  as  a  rigor  or 
chill.  In  severe  cases  the  shivering  is  accompanied  by  the 
sensation  of  intense  cold,  especially  referred  to  the  back  and 
spine;  the  surface  is  cold  to  the  touch,  the  teeth  chatter, 
the  features  are  blue  and  pinched,  the  pulse  is  small,  hard, 
and  rapid,  and  the  vitality  greatly  depressed.  The  par- 
oxysm may  be  so  violent  that  the  bed  on  which  the 
patient  lies  is  actually  shaken.  The  temperature  for  a 
short  time  is  subnormal,  but  rapidly  rises.  The  attack 
lasts  from  a  few  minutes  to  half  an  hour  or  more.  In  cases 
of  malaria  the  characteristic  rigor  frequently  lasts  an  hour. 

A  short  time  after  the  shivering  has  stopped,  a  rigor  is 
followed  by  a  hot  stage,  the  characteristic  symptoms  of 
which  are  high  temperature,  full,  bounding  pulse,  headache, 
a  hot  dry  skin,  and  other  evidences  of  fever. 

A  rigor  always  has  a  definite  signification.  It  is  the 
usual  accompaniment  of  the  onset  of  all  infectious  fevers 
that  begin  abruptly,  such  as  pneumonia,  erysipelas,  etc.; 
of  all  septic  conditions,  especially  when  accompanied  by 
suppuration,  and  is  the  characteristic  symptom  of  the 
first  stage  of  an  attack  of  malaria.  Occurring  in  connec- 
tion with  an  open  wound,  as  after  an  operation,  or  in  the 
course  of  an  acute  illness,  a  rigor  indicates  some  suppura- 
tive  process.  In  all  intermittent  fevers  (see  Fever)  the 
rise  of  temperature  is  usually  accompanied  by  rigors  of 


720      SYMPTOMS  AND    CONDITIONS   FREQUENTLY   MET 

more  or  less  severity.  In  these  cases  the  hot  stage,  which 
may  last  but  a  short  time  or  for  several  hours,  is  followed 
by  a  stage  of  sweating  in  which  the  temperature  again  falls. 

Not  infrequently  prolonged  or  difficult  catheterization 
is  followed  by  a  rigor  and  rise  in  temperature.  The  rigor 
may  be  purely  nervous  in  its  origin,  in  which  case  the  tem- 
perature does  not  remain  high  and  the  acute  symptoms 
quickly  subside.  More  often  the  rigor  indicates  infection 
from  a  non-sterile  catheter,  unclean  hands,  etc.,  and  ushers 
in  an  attack  of  septic  cystitis.  A  nervous  chill  may 
follow  an  accident  or  severe  strain.  Although  frequently 
quite  severe,  it  is  not  followed  by  any  marked  rise  in  tem- 
perature or  other  symptoms  of  fever. 

As  a  rule,  children  do  not  have  rigors.  Conditions  that 
in  an  adult  would  be  associated  with  rigor,  in  a  child  are 
usually  accompanied  by  convulsions. 

The  treatment  of  a  rigor  is  the  application  of  warmth — 
warm  coverings,  hot-water  bottle,  and  hot  drinks.  Fre- 
quently stimulation,  such  as  hot  whisky  and  water,  is 
ordered.  The  patient  should  be  kept  in  bed  and  carefully 
protected  from  draughts.  The  hot  stage  is  treated  with 
light  covering,  an  ice-bag  to  the  head,  and  plenty  of  water 
to  drink.  The  pulse,  and,  where  practical,  the  temperature, 
should  be  taken  at  the  beginning  of  a  rigor,  immediately 
after,  and  again  in  half  an  hour's  time.  The  duration  of 
the  rigor,  the  pulse  and  temperature,  and  any  other  prom- 
inent symptoms  should  be  carefully  recorded  on  the  chart. 

SWEATING 

An  attack  of  profuse  sweating,  or  diaphoresis,  is  the  com- 
mon feature  of  any  crisis  following  a  period  of  high  tem- 
perature. (See  Crisis.)  In  such  condition  it  is  a  favorable 
sign,  and  is  accompanied  by  a  fall  of  temperature  and  a 
general  condition  of  improvement.  A  typical  example 
of  a  favorable  diaphoresis  is  the  profuse  sweating  in  the 
third  stage  of  a  malarial  paroxysm. 

Accompanying  a  condition  of  profoundly  lowered  vital- 
ity or  general  collapse,  with  clammy  skin,  cold  extremities, 
and  small  feeble  pulse,  sweating  is  an  unfavorable  symp- 
tom. It  may  be  associated  with  a  high  or  a  subnormal  tern- 


SWEATING  721 

perature.  Such  a  condition  is  frequently  seen  shortly 
before  death. 

Severe  sweating,  usually  occurring  at  night,  is  a  common 
feature  of  enfeebled  conditions  associated  with  hectic  fever, 
such  as  the  later  stages  of  tuberculosis  and  septicemia. 

Periodic  attacks  of  sweating  are  a  common  symptom  in 
acute  inflammatory  rheumatism;  the  sweat  is  peculiarly 
acid  and  has  a  characteristic  sour  smell.  Attacks  of 
sweating  are  also  a  characteristic  accompaniment  of  the 
convulsions  of  tetanus. 

Sweating  may  also  be  produced  by  great  pain  or  by 
emotion,  especially  fear.  In  the  latter  case  it  is  preceded 
by  the  creeping  sensation  known  as  goose-flesh,  due  to  the 
contraction  of  the  minute  muscles  attached  to  the  roots  of 
the  hair. 

Sweating  may  be  induced  artificially  by  the  applica- 
tion of  external  heat,  such  as  the  sweat-bath,  hot  pack,  etc. 
(Chap.  II),  and  by  the  action  of  certain  drugs  known  as 
diaphoretics. 

The  treatment  of  sweating  lies  in  keeping  the  patient 
warm,  dry,  and  protected  from  exposure  to  chill  or  drafts. 
While  the  sweating  continues,  he  should  be  closely  covered, 
preferably  with  material  that  will  absorb  the  sweat,  such 
as  flannel  or  blankets.  If  a  cotton  shirt  is  worn,  it  is  best 
to  remove  it  at  once,  as  when  wet  it  has  a  chilling  effect. 
When  the  sweating  ceases,  the  skin  should  be  quickly 
dried  with  hot  towels,  and  the  wet  clothing  changed,  the 
whole  process  being  carried  out  strictly  under  cover.  A 
brisk  alcohol  rub  may  be  added  where  practical,  and  will 
help  to  check  a  continuance  of  the  sweating. 

The  sweating  of  tuberculosis  is  reduced  by  methods  that 
reduce  the  fever,  especially  sleeping  and  living  in  the  open 
air.  To  some  extent  tepid  or  astringent  sponging,  such  as 
vinegar  and  water,  has  a  beneficial  effect  on  the  sweating 
of  feverish  conditions.  The  bed-coverings  should  not  be 
heavy;  if  necessary,  warmth  may  be  supplied  by  the  hot- 
water  bag  or  the  use  of  woolen  socks. 

The  sweating  of  rheumatic  fever  is  frequently  indirectly 
treated  by  hydrotherapeutic  measures,  such  as  cold  bath- 
ing or  sponging.  The  patient  should  sleep  between  blan- 

46 


722      SYMPTOMS   AND    CONDITIONS   FREQUENTLY  MET 

kets  and  wear  a  flannel  shirt.  To  remove  the  disagree- 
able odor  of  the  sour  perspiration,  sponging  with  hot 
water  or  hot  water  and  vinegar  is  generally  practised. 
It  must  not  be  begun  until  the  diaphoresis  is  completely 
over. 

Certain  drugs  have  the  property  of  checking  sweating 
(anhydrotics) ;  that  in  most  general  use  is  belladonna,  with 
its  alkaloid,  atropin. 

Unilateral  sweating,  or  sweating  confined  to  one  side  of 
the  face,  is  a  phenomenon  that  occurs  from  pressure  on 
certain  nerves  of  the  sympathetic  system,  either  from  a 
thoracic  aneurysm  or  other  tumor. 

Sudamen. — A  peculiarly  pretty  eruption  of  minute, 
pearly  vesicles  is  known  as  sudamen.  It  consists  of  fine 
beads  of  perspiration  that  have  become  imprisoned  in  the 
upper  layer  of  the  skin.  It  is  usually  seen  in  connection 
with  free  perspiration.  The  condition  requires  no  treat- 
ment; the  vesicles  dry  up,  leaving  a  superficial  desquama- 
tion. 

FEVER 

A  condition  in  which  the  body  temperature  is  raised 
above  100°  F.  is  said  to  be  one  of  fever.  A  raised  tempera- 
ture is  a  common  feature  of  many  physical  disturbances 
(see  Temperature).  By  the  term  fever  in  its  more  re- 
stricted sense  we  understand  a  condition  in  which  the  tem- 
perature is  persistently  raised  for  certain  defined  periods, 
the  rise  being  associated  with  a  group  of  characteristic 
physical  symptoms. 

The  cause  of  fever  in  the  majority  of  cases  is  attributed  to 
the  presence  in  the  blood  of  toxins  or  poisons  (Chap.  XI), 
usually  the  production  of  bacterial  activity.  These  are  the 
so-called  infectious  fevers,  such  as  typhoid  fever,  smallpox, 
malaria,  and  others.  In  other  cases  the  toxins  are  sub- 
stances produced  by  the  natural  activity  of  the  body,  which, 
owing  to  defective  elimination,  have  entered  the  circula- 
tion. Such  are  the  toxins  in  uremia  or  in  auto-intoxica- 
tion. A  fever  not  due  to  infection,  but  the  result  of 
overfatigue,  gastric  disturbances,  exposure  to  heat,  etc.,  is 
known  as  simple  continued  fever.  Conditions  in  which  the 


FEVER  723 

secretions  of  the  body  are  abruptly  checked  are  also  associ- 
ated with  fever.  A  mild  example  is  the  fever  attending  the 
common  "  cold  ";  a  grave  example,  the  high  fever  of  heat- 
stroke. 

The  physical  symptoms  that  accompany  fever  are — 
malaise,  chilliness,  headache,  nausea,  loss  of  appetite, 
thirst,  constipation  (or,  less  frequently,  diarrhea),  and 
coated  tongue.  The  pulse  is  full  and  bounding;  both 
pulse  and  respiration  are  quickened  in  proportion  to  the 
rise  of  temperature  (see  Temperature).  The  skin  is  hot 
and  dry,  the  face  flushed,  the  mouth  parched,  the  urine 
scanty  and  concentrated,  and  frequently  albuminous;  the 
patient  is  restless  and  sleep  is  disturbed.  When  fever 
begins  abruptly,  the  chilliness  may  be  severe  and  takes  the 
form  of  rigors.  As  already  said,  in  children  convulsions 
usually  take  the  place  of  rigors.  An  abrupt  onset  in  chil- 
dren is  usually  also  characterized  by  a  sudden  attack  of 
vomiting. 

As  the  fever  progresses,  further  symptoms  are  prostration, 
emaciation,  and  nervous  symptoms — insomnia,  startling 
dreams,  and,  in  severe  cases,  delirium  or  coma.  The 
coated  tongue  has  a  tendency  to  become  heavily  furred, 
dry,  and  fissured. 

The  symptoms  that  mark  the  beginning  of  a  fever  are 
called  prodromes.  The  most  common  are  malaise,  chilli- 
ness, headache,  loss  of  appetite,  gastric  disturbance  and 
restlessness,  and,  in  children,  vomiting.  It  is  to  the  pro- 
dromes we  refer  when  we  talk  of  a  person  "  sickening  " 
for  an  illness.  In  many  of  the  specific  fevers  there  are 
characteristic  prodromes.  For  example,  in  measles  there 
is  a  characteristic  coryza;  in  scarlet  fever,  soreness  of  the 
throat;  in  smallpox,  agonizing  pain  in  the  back  and  limbs. 

Course. — A  fever  is  divided  into  three  periods:  the 
invasion  or  onset,  the  fastigium,  also  called  the  stadium, 
and  the  decline  (p.  199).  In  the  specific  fevers  the  average 
length  of  duration  of  each  period  varies  within  the  different 
infections.  During  the  invasion  period  the  temperature 
rises  and  the  characteristic  symptoms  gradually  develop; 
during  the  fastigium  the  temperature  remains  at  or  near 
its  highest  point,  with  certain  variations  in  each  twenty-four 


724      SYMPTOMS   AND   CONDITIONS   FREQUENTLY   MET 

hours;  the  symptoms  are  intensified,  especially  the  ner- 
vous symptoms,  and  emaciation,  which  progresses  rapidly. 
During  the  period  of  decline  the  temperature  falls  until  the 
normal  is  regained;  in  favorable  cases  all  the  symptoms 
improve.  The  skin  begins  to  act  naturally,  the  urine  is 
increased  in  quantity,  the  bowels  are  less  constipated, 
some  diarrhea  is  frequently  present,  sleep  is  natural,  the 
tongue  becomes  moist  and  clean,  and  the  mental  condition 
improves.  During  the  decline,  prostration  is  a  prominent 
symptom ;  it  is  especially  at  this  time  that,  unless  carefully 
supported,  the  overtaxed  heart  may  fail. 

In  some  fevers  the  invasion  is  abrupt,  the  temperature 
rising  rapidly  in  a  few  hours  to  a  considerable  height,  in 
others  the  rise  is  slow,  the  temperature  rising  and  falling 
from  day  to  day,  but  each  daily  scale  of  temperature  being 
higher  than  that  of  the  proceeding  twenty-four  hours. 
The  invasion  is  then  described  as  gradual.  A  decline 
occurring  abruptly  is  called  a  crisis;  occurring  gradually,  a 
lysis.  Only  a  few  fevers  commonly  terminate  by  crisis. 
They  are  pneumonia,  measles,  typhus  fever,  erysipelas, 
malaria,  relapsing  fever,  and,  frequently,  influenza. 

A  crisis  is  accompanied  by  marked  characteristic  symp- 
toms. They  are  profuse  perspiration,  a  large  increase  in 
the  quantity  of  urine,  frequently  diarrhea,  sensations  of 
chilliness  or  shivering,  unless  the  body  is  well  protected. 
Some  prostration  is  always  present,  and  there  is  risk  of 
sudden  cardiac  failure.  In  favorable  cases  the  patient 
falls  into  a  natural  sleep  and  awakens  refreshed. 

At  the  end  of  the  decline  convalescence  is  established. 
Daily  variations  in  the  temperature  are  known  as  remissions 
(see  Temperature).  Where  the  remissions  are  slight, 
not  more  than  a  degree  to  a  degree  and  a  half,  the  fever  is 
said  to  be  continued.  Where  the  remissions  are  greater, 
but  where  the  whole  scale  of  temperatures  is  entirely  above 
normal,  that  is  to  say,  fever  is  always  present,  the  fever 
is  said  to  be  remittent.  A  few  characteristic  paroxysms  of 
high  temperature  followed  by  remissions,  in  which  the 
temperature  falls  to  normal  or  subnormal,  is  described  as 
intermittent;  that  is  to  say,  in  an  intermittent  fever  there 
is  a  period  in  which  there  is  no  fever.  This  period  may  be 


FEVER  725 

a  daily  remission,  lasting  a  few  hours,  as  in  many  forms  of 
septicemia,  or  it  may  occur  after  a  short,  acute  access  of 
fever  and  last  for  one  or  more  days,  as  in  the  different  forms 
of  malaria;  or  again,  a  period  of  continued  fever,  lasting  sev- 
eral days,  may  be  followed  by  an  intermission  of  several 
days,  as  in  relapsing  fever.  In  intermittent  fever  the 
characteristic  symptoms  of  invasion,  fastigium,  and  decline 
are  present  in  an  aggravated  form  and  follow  each  other 
with  great  rapidity.  Then,  as  the  fever  rises,  we  have  an 
acute  attack  of  shivering,  followed  quickly  by  the  flushed 
face,  hot  skin,  full  pulse,  high  temperature,  and  other 
symptoms  of  the  fastigium.  The  decline  occurs  as  a  crisis, 
with  profuse  sweating,  increased  urine,  exhaustion,  and 
a  disposition  to  sleep. 

The  fever,  during  a  gradual  invasion  and  toward  the  end 
of  a  lysis,  is  commonly  remittent.  During  the  fastigium  it 
is  generally  continued.  In  fevers  beginning  abruptly  and 
ending  by  crisis,  such  as  pneumonia  or  typhus  fever,  the 
fever  is  continuous  during  the  whole  course  of  the  disease. 
In  typhoid  fever,  as  a  rule,  the  fever  is  remittent  not  only 
during  the  invasion  and  lysis,  but  also  during  the  fastigium. 
Remittent  fever  lasting  three  weeks  is  one  of  the  diagnostic 
symptoms  of  the  disease.  In  acutely  septic  conditions, 
associated  with  the  formation  of  pus,  intermittent  fever  is 
common. 

Fevers  that  do  not  belong  definitely  to  either  class,  but 
may  evince  in  their  course  the  characteristics  of  two  or 
all  three,  are  described  as  irregular.  The  fever  in  tetanus, 
and  frequently  in  diphtheria,  is  irregular. 

Long,  protracted  fever  is  sometimes  called  hectic;  as  a 
rule,  it  is  of  the  intermittent  variety.  It  is  common  in 
septic  conditions  and  generally  accompanies  the  last  stages 
of  tuberculosis. 

Incubation  Period. — In  the  specific  infectious  fevers  the 
period  occurring  between  the  exposure  to  infection  and 
the  beginning  of  the  invasion  is  known  as  the  incubation 
period. 

Duration  of  Periods. — The  table  on  p.  726  gives  the 
average  duration  of  the  different  periods  in  the  more  com- 
mon infectious  fevers. 


r26      SYMPTOMS   AND    CONDITIONS   FREQUENTLY   MET 


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FEVER  727 

ERUPTIVE   FEVERS 

Certain  acute  infectious  fevers  are  characterized  by  the 
presence  of  a  skin  eruption  or  rash;  they  are  classed  as  the 
eruptive  or  exanthematous  fevers.  In  each  case  the  rash 
presents  a  characteristic  appearance.  It  is  usually  first 
observed  over  some  special  area,  appears  on  a  certain  day 
of  the  disease,  and  is  followed  by  a  more  or  less  extensive 
shedding  of  the  upper  layer  of  the  skin,  a  process  known 
as  desquamation.  The  shed  particles  should  be  regarded 
as  infectious.  Desquamation  is  described  as  branny  (a 
powdery  shedding  of  the  surface  skin),  or  may  occur  in 
scales,  flakes,  or  crusts. 

The  first  day  of  disease  is  taken  as  the  first  day  of  abnor- 
mal symptoms,  such  as  shivering,  vomiting,  malaise,  and 
rise  of  temperature. 

Varicella,  or  Chicken-pox. — Rash  appears  on  the  first 
day  of  the  disease. 

Character. — Rose-red  papules  which,  except  in  mild 
cases,  rapidly  become  vesicular.  Intense  itching  is 
usually  present. 

Distribution. — The  rash  appears  simultaneously  all 
over  the  body,  coming  out  in  groups.  The  vesicles  are 
superficial,  become  pustules,  and  dry  up  in  two  or  three 
days.  The  cuticle  is  shed  in  the  form  of  thin  crusts,  con- 
sidered moderately  infectious. 

Infection  is  considered  to  last  until  the  crusts  have  all 
been  removed  and  the  skin  is  entirely  healed. 

Scarlet  Fever. — Rash  appears  on  the  second  day  of  the 
disease,  that  is  to  say,  between  twenty-four  and  forty- 
eight  hours. 

Character. — Diffuse,  scarlet  (erythematous),  punctiform 
eruption,  effaced  by  pressure.  A  quick  stroke  with  the 
finger  across  the  rash  will  leave  a  white  line  lasting  several 
moments. 

Distribution. — The  rash  appears  first  on  the  chest  and 
neck  and  rapidly  covers  the  whole  body.  The  whole 
face  is  involved,  except  an  area  round  the  nose  and  mouth, 
which  remains  pallid;  the  rash  lasts  from  five  to  seven  days, 
gradually  fading,  and  followed  by  profuse  flaky  desquama- 


728      SYMPTOMS    AND    CONDITIONS   FREQUENTLY   MET 

tion,  the  particles  of  which  are  considered  extremely 
infectious. 

Infection  lasts  until  the  desquamation  has  entirely 
ceased — usually  from  six  to  eight  weeks.  Infection  will 
last  beyond  this  period  if  there  should  be  discharges  from 
nose,  ears,  or  suppurating  glands. 

The  scarlet-fever  rash  is  typical  of  many  other  rashes 
caused  by  accidental  conditions  (Chap.  VI);  the  expres- 
sion scarlatinous  rash  is  frequently  used  to  describe  them. 
The  association  of  scarlet  fever  with  special  physical  symp- 
toms, in  particular  with  acute  sore  throat,  and  a  char- 
acteristic appearance  of  the  tongue,  known  as  the  straw- 
berry tongue,  and  the  characteristic  distribution  of  the  rash 
confirms  the  diagnosis. 

Smallpox. — Rash  appears  on  the  third  day  of  the  disease. 

Character. — Small,  round,  red  papules,  feeling  like  shot 
beneath  the  skin,  which  develop  into  vesicles  and  finally 
become  pustular.  Papules,  vesicles,  and  pustules  (p. 
246)  may  be  seen  together  on  small  areas.  As  the  rash 
appears  the  temperature  usually  falls  somewhat  and  rises 
again  as  the  rash  becomes  pustular,  about  the  eighth  day. 
When  the  eruption  is  so  copious  that  the  papules  run 
together,  the  rash  is  said  to  be  confluent. 

Distribution. — The  eruption  occurs  first  on  the  forehead, 
face,  and  wrists,  finally  involving  the  whole  body. 

Desquamation  occurs  in  scales  with  a  peculiar  offensive 
odor,  each  scab  leaving  behind  a  pit  or  pock  which  remains 
for  a  long  time  after  the  spot  is  healed  and  may  be  per- 
manent. 

Infection  is  considered  to  continue  until  the  skin  is 
entirely  healed. 

Measles  (Rubeola). — Rash  appears  on  the  fourth  day  of 
the  disease. 

Character. — Macular  and  papular  spots  (p.  246),  dark 
red  in  color,  and  usually  occurring  in  groups  forming  a 
crescent. 

Distribution. — The  rash  appears  first  on  the  face,  usually 
the  forehead,  and  spreads  rapidly  over  the  body.  It 
fades  in  from  three  to  four  days,  followed  by  branny  des- 
quamation. Itching  is  a  frequent  symptom.  A  few  small, 


FEVER  729 

bluish-white  specks,  scattered  on  the  mucous  membrane 
of  the  cheeks  and  lips,  may  frequently  be  observed  before 
the  rash  develops.  They  are  known  as  Koplik's  spots. 
The  acute  catarrhal  condition  of  the  nose  and  eyes  which 
accompanies  the  onset  of  the  disease  confirms  the  diagnosis. 

Infection  lasts  until  the  skin  is  quite  free  from  desquama- 
tion  or  until  all  discharge  from  the  ears  or  nose  has  stopped. 

German  Measles  (Rubella  or  Roseola). — Rash  appears 
on  the  first  or  second  day  of  the  disease. 

Character. — It  may  resemble  either  the  papular  rash  of 
measles  or  the  diffuse,  bright-red  rash  of  scarlet  fever. 

Distribution. — It  appears  first  on  the  face  or  behind  the 
ears,  and  rapidly  spreads  over  the  body.  It  fades  very 
quickly,  leaving  a  slight  branny  desquamation.  It  is 
distinguished  from  scarlet  fever  or  measles  by  the  slight 
physical  symptoms  and  the  rapidity  with  which  the  rash 
fades  and  convalescence  is  established. 

Typhus  Fever. — Rash  appears  between  the  fourth  and 
eighth  days. 

Character. — Petechial  rash  (p.  247).  The  spots  are 
first  rose  colored,  then  fade  to  a  purplish  hue  known  as 
mulberry  rash. 

Distribution. — The  rash  occurs  on  the  body,  and  is 
slight  or  diffuse,  as  the  attack  is  mild  or  severe. 

Typhoid  Fever. — Rash  appears  in  successive  crops 
from  the  seventh  to  the  fourteenth  day. 

Character. — Rose-colored,  isolated,  lenticular  (p.  246) 
papules,  which  disappear  on  pressure;  frequently  called 
typhoid  spots. 

Distribution. — The  papules  most  frequently  appear  in 
groups  of  two  or  three  spots  on  the  abdomen,  but  they  may 
develop  on  the  chest,  back,  or,  more  rarely,  on  the  extrem- 
ities. Frequently  the  rash  is  entirely  absent  or  repre- 
sented by  one  or  two  spots.  Each  spot  forms  for  two  or 
three  days,  and  then  fades.  Very  slight  local  desquama- 
tion may  follow.  Other  physical  symptoms  of  typhoid 
are  usually  so  marked  that  the  rash,  in  many  instances, 
is  of  slight  diagnostic  importance. 


730      SYMPTOMS   AND   CONDITIONS   FREQUENTLY  MET 

OTHER  SKIN  ERUPTIONS 

Erysipelas.— Erysipelas  is  classed  as  one  of  the  exan- 
thematous  fevers.  The  rash  is,  however,  more  an  acute 
local  inflammation  of  the  skin. 

Rash  appears  on  the  first  day  of  the  disease. 

Character. — The  area  is  swollen,  hard,  and  bright  red 
or  crimson  in  color,  with  a  well-defined  margin,  frequently 
raised,  beyond  which  the  skin  has  its  normal  color.  The 
affected  surface  has  a  glossy,  polished  appearance;  later 
vesicles  and  blebs  form,  and  in  some  cases  suppuration 
occurs.  The  tissues  in  the  vicinity  are  edematous. 

Distribution. — It  occurs  at  a  spot  in  the  vicinity  of, 
though  somewhat  remote  from,  the  wound  through  which 
the  microbe  has  gained  entrance.  For  example:  in  infec- 
tion through  a  wound  on  the  body  the  rash  may  appear  on 
one  of  the  extremities.  In  facial  erysipelas  the  rash  begins 
about  the  nose,  and  spreads  until  the  whole  face  is  in- 
volved, usually  stopping  short  at  the  roots  of  the  hair  and 
the  neck. 

The  rash  in  erysipelas  lasts  for  four  or  five  days,  then 
fades,  and  the  inflammation  subsides;  the  desquamation 
may  be  branny  or  occur  in  flakes. 

Infection  is  considered  to  continue  as  long  as  there  is 
any  desquamation. 

Syphilis. — The  different  stages  of  syphilis  are  marked 
by  varieties  of  skin  eruptions,  usually  occurring  in  local- 
ized areas.  In  the  earlier  stages  (secondary  syphilis)  the 
rash  is  commonly  macular  or  papular,  and  has  a  char- 
acteristic dark-red  color,  described  as  ham  color  or  cop- 
pery; subsequently  the  rash  may  become  pustular  and 
lead  to  superficial  ulceration,  or  break  down  into  moist 
papules  or  mucous  patches.  This  occurs  usually  in  warm, 
moist  areas,  such  as  beneath  the  breasts,  under  the  arms, 
round  the  mouth,  etc.  Pustules  either  become  reabsorbed 
or  lead  to  the  formation  of  characteristic  ulcers. 

In  the  later  stages  of  syphilis  (tertiary  syphilis)  tubercles 
(p.  246),  gummatous  nodules,  and  blebs  filled  with  purulent 
fluid  are  common.  A  gummatous  nodule  is  one  that  be- 
comes soft  or  gummy  in  character.  The  eruption  may  dry 
up  and  become  absorbed.  Commonly  they  produce  ulcera- 


FEVER  731 

tion  and  leave  behind  the  typical  syphilitic  ulcer,  which  has 
a  punched-out  surface,  covered  with  thick,  offensive  dis- 
charge. In  dressing  these  ulcers  the  greatest  care  must 
be  taken  or  the  dresser  may  become  inoculated  through 
any  small  abrasion  on  his  own  hands. 

From  the  above  it  will  be  seen  that  the  date  of  the  appear- 
ance, the  character  and  distribution  of  the  rash,  and  the 
subsequent  desquamation  are  all  points  of  diagnostic 
importance  and  must  be  accurately  noted. 

Accidental  Rashes. — Many  conditions  of  acute  gastric 
irritation,  especially  in  children,  are  accompanied  by  a 
scarlatinous  or  erythematous  rash.  The  physical  symp- 
toms are  pronounced  and  the  fever  high.  Frequently 
distribution  of  the  rash  begins  in  the  vicinity  of  the  abdo- 
men, and  the  absence  of  acute  sore  throat  or  strawberry 
tongue  distinguishes  it  from  scarlet  fever.  An  erylhe- 
matous  rash  may  also  follow  exposure  to  cold.  Other 
accidental  rashes  are  caused  by  poisoning  by  certain 
drugs.  Atropin  or  belladonna  produces  an  erythematous 
rash  resembling  scarlet  fever,  but  on  close  examination  the 
punctiform  character  is  absent.  •  Salicylic  compounds  and 
quinin  also  frequently  produce  an  erythematous  rash. 
Poisonings  by  many  of  the  coal-tar  products,  such  as  anti- 
pyrin,  may  frequently  cause  a  papular  rash.  The  irritant 
poisons,  such  as  arsenic,  may  produce  either  an  erythe- 
matous or  a  papular  rash.  An  acne  rash  (see  below)  is 
a  characteristic  symptom  of  bromidism  and  iodism.  The 
continued  use  of  chloral  may  be  followed  by  an  erythe- 
matous rash.  A  transitory  diffuse  rash,  caused  by  the  di- 
latation of  the  superficial  blood-vessels,  frequently  appears 
about  the  neck  and  chest  during  the  administration  of 
ether. 

The  more  common  skin  eruptions  not  associated  with 
skin  diseases  are  as  follows : 

Herpes  (fever-blister,  cold  sore)  appears  in  small  groups 
of  minute  vesicles,  usually  about  the  lips.  It  is  common 
in  many  catarrhal  and  feverish  conditions.  It  is  nearly 
always  present  in  lobar  pneumonia.  The  vesicles  are 
usually  treated  with  a  simple  ointment,  such  as  oxid  of  zinc, 
and  dry  up  and  diasappear  in  from  three  to  five  days. 


732      SYMPTOMS  AND  CONDITIONS   FREQUENTLY  MET 

Herpes  Zoster  (Shingles). — The  vesicles  are  distributed 
over  the  course  of  a  superficial  nerve,  more  commonly  over 
one  side  of  the  body  or  about  the  face,  round  the  eyes;  the 
eye  itself  may  be  involved,  causing  intense  pain.  The 
condition  is  usually  associated  with  acute  neuralgic  pain 
which  is  most  intense  before  the  eruption  appears. 

Herpes  zoster  is  generally  considered  to  be  of  nervous 
origin,  though  it  may  result  from  exposure  to  wet  and  cold, 
usually  from  wearing  wet  garments  next  the  skin. 

A  dressing  of  simple  ointment  is  first  applied,  and  the 
general  health  attended  to.  The  neuralgic  pain  is  fre- 
quently relieved  by  phenacetin. 

Urticaria  (Hives,  Nettle-rash). — The  rash  usually  ap- 
pears in  successive  crops,  either  as  rose-colored  papules 
or  as  white  wheals  on  a  red  surface.  Each  crop  lasts  a 
few  hours  and  causes  intense  itching.  Urticaria  is  fre- 
quently a  result  of  mild  poisoning  from  shell-fish,  certain 
acid  fruits,  especially  strawberries,  or  from  poisoning 
by  poison-ivy  or  similar  weeds.  Some  persons  are  pecu- 
liarly susceptible  to  the  condition.  To  allay  the  itching 
the  surface  may  be  sponged  with  a  solution  of  carbolic 
acid  (2  per  cent.)  or  with  equal  parts  of  alcohol  and  water. 
If  due  to  a  gastric  condition,  a  purgative  is  usually  ad- 
ministered. 

Erythema  Simplex,  or  Stomach  Rash. — A  simple,  diffuse 
scarlatinous  rash,  not  caused  by  a  specific  disease,  is  des- 
cribed as  simple  erythema.  It  may  be  due  to  gastric 
disturbances  or  poisoning  by  certain  drugs,  as  mentioned 
above;  to  exposure  to  heat  or  cold,  especially  to  sudden 
changes  of  temperature  from  excessive  cold  to  excessive 
heat,  and,  not  infrequently,  to  the  effects  of  antitoxin. 

Erythema  Nodosum. — The  rash  appears  in  circum- 
scribed, slightly  raised,  irregular,  rose-colored  patches, 
usually  over  the  front  of  the  legs.  The  condition  is  accom- 
panied by  general  malaise,  some  fever,  and  rheumatic 
pains  in  the  joints.  It  may  be  associated  with  rheuma- 
tism, gastric  disorders,  and  malnutrition.  The  condition 
is  more  common  in  childhood. 

In  fading,  the  patches  change  color,  turning  yellow, 
blue,  and  green,  like  a  bruise. 


FEVER  733 

Local  applications  of  lead-water  or  lead-water  and  laud- 
anum are  usually  applied,  and  the  general  health  is  attended 
to,  the  patient  remaining  in  bed.  The  condition  lasts  a 
few  weeks. 

Erythema  Intertrigo  (Chafing}. — A  local  inflammation, 
occurring  where  two  surfaces  of  the  skin  rub  together,  as 
in  the  groins,  under  the  breasts,  and  between  the  buttocks. 
Cleanliness  and  care  in  keeping  the  places  dry  prevent  this 
condition.  The  affected  part  appears  first  red,  then  moist, 
and,  if  the  condition  is  allowed  to  continue,  will  become 
macerated.  The  surfaces  should  be  kept  apart,  and  a 
simple  dressing,  such  as  zinc  ointment,  applied. 

Acne  Rash. — An  eruption  of  small  papules  frequently 
developing  into  pustules  is  common  about  the  face,  shoul- 
ders, and  chest,  especially  in  young  girls  about  the  age  of 
puberty.  Generally  it  is  associated  with  physical  debility 
or  menstrual  or  gastric  disorders.  Small  blackheads  are 
usually  present,  due  to  occlusion  of  some  of  the  sweat- 
ducts.  They  may  be  removed  by  pressing  with  a  watch-key. 

In  most  cases  the  condition  is  due  to  a  parasite.  The 
scalp  should  be  examined,  as  in  many  instances  the  skin 
is  infected  from  dandruff  falling  on  the  body  when  the 
hair  is  brushed.  The  use  of  special  antiseptic  ointments 
and  lotions  is  usually  prescribed,  and  attention  to  good 
hygiene  and  the  improvement  of  the  general  health. 

The  various  forms  of  skin  disease  are  accompanied  by 
characteristic  eruptions,  to  recognize  all  of  which  involves 
a  special  study  of  the  subject.  The  various  forms  of 
eczema  are  described  as  papular,  pustulous,  or  squamous, 
according  to  the  characteristics  of  the  eruption.  The  fol- 
lowing skin  affections,  however,  may  frequently  be  met 
with,  especially  in  an  out-patient  department  or  in  dis- 
trict work,  and  it  is  of  importance  that  their  characteristic 
appearance  should  early  be  recognized. 

Scabies  Itch. — Scabies  is  caused  by  an  animal  parasite, 
the  female  of  which  burrows  under  the  skin  in  order  to 
deposit  her  eggs.  The  line  of  burrowing  and  deposition 
of  the  eggs  is  marked  by  short,  red,  slightly  raised  dotted 
lines,  about  one-half  inch  in  length.  The  accompanying 
line  of  eruption  is  papular,  the  papules  frequently  forming 


734      SYMPTOMS   AND   CONDITIONS   FREQUENTLY   MET 

vesicles  or  minute  pustules.  The  itching  is  severe.  The 
condition  is  highly  contagious,  especially  through  the 
clothing,  towels,  etc.  Nurses  in  out-patient  departments 
may  frequently  be  exposed  to  this  contagion.  If  the 
infection  is  contracted,  a  doctor  should  be  consulted  at 
once,  and  the  greatest  care  exercised  in  disinfecting 
sheets,  towels,  etc.,  before  sending  them  to  the  general 
laundry.  The  treatment  usually  advised  is  a  hot  tub- 
bath  at  bedtime,  following  which  an  ointment,  generally 
sulphur,  is  well  rubbed  into  the  affected  area.  The  doctor 
should  be  seen  every  few  days,  as  the  treatment  itself 
might  cause  irritation  to  the  skin. 

A  non-infectious  eruption  of  red  papules,  intensely 
itching,  is  common  in  agricultural  districts  about  harvest 
time.  It  is  also  due  to  an  insect  that  deposits  its  eggs 
under  the  skin.  The  itching  may  be  relieved  by  sponging 
with  carbolic  and  water  (2  per  cent.)  or  alcohol  and  water 
(equal  parts). 

Pediculosis. — The  bite  of  a  louse,  an  insect  that,  in 
filthy  conditions,  inhabits  the  human  hair,  either  on  the 
head,  pubes,  or  about  the  body,  produces  an  intense  itch- 
ing and  an  appearance  as  of  red  papular  rash.  The  dis- 
covery of  the  lice,  and  of  small  translucent  bodies  clinging 
to  a  separate  hair,  which  are  their  eggs,  determines  the 
cause  (p.  86).  On  close  examination  the  bite  of  the 
insect  can  be  seen  in  the  individual  papule. 

Ringworm. — Tinea  Tricophytina. — The  eruption  may 
occur  on  the  head  (tinea  tonsurans),  on  the  beard  (tinea 
sycosis),  or  on  the  body  (tinea  circinata),  and  is  caused  by 
a  vegetable  parasite  which  attacks  the  roots  of  the  hair. 
The  form  most  commonly  met  with  is  the  scalp  ringworm 
among  children.  This  ringworm  consists  of  round,  red, 
elevated  patches;  the  patches  at  first  are  slightly  raised, 
with  the  hair-follicles  prominent;  later  they  are  grayish 
and  scaly,  and  the  hairs  of  the  roots  involved  are  dry, 
discolored,  brittle,  and  easily  pulled  out.  The  center  of 
the  patch  clears*  first,  leaving  the  characteristic  ring; 
the  condition  is  highly  contagious,  the  infection  being 
readily  carried  by  clothing,  etc.,  or  direct  contact  with 
the  hair  by  another  child. 


FEVER  735 

The  treatment  usually  consists  in  keeping  the  head  clean 
by  daily  washing,  following  which  the  diseased  hairs  are 
pulled  out  and  an  ointment,  usually  of  sulphur  or  of 
mercury,  rubbed  into  the  affected  part.  The  hair  of 
the  affected  parts  should  be  either  cropped  close  or  kept 
closely  braided  to  avoid  coming  in  contact  with  the  ring- 
worm. 

Ringworms  of  the  body  are  round,  scaly,  reddened 
patches,  covered  with  minute  vesicles.  The  inflammation 
disappears  first  from  the  center,  leaving  the  ring  formation. 
An  ointment  containing  mercury  or  sulphur  is  usually 
applied,  and  the  clothes  should  be  carefully  disinfected 
and  strict  cleanliness  observed. 

Tinea  favosa  (favus)  is  a  severe  form  of  ringworm  due  to 
another  form  of  parasite.  It  involves  large  areas  of  the 
scalp.  The  infected  portion  is  covered  with  cup-shaped 
crusts,  presenting  an  appearance  somewhat  like  a  honey- 
comb. The  hairs  are  dry,  brittle,  and  broken  off  short. 
The  crusts  have  an  offensive,  musty  odor.  Usually  the 
crusts  are  softened  by  poulticing  or  the  application  of 
warm  oil,  after  which  they  are  removed  by  washing. 
The  treatment  consists  in  the  removal  of  each  hair  by 
forceps,  and  the  daily  application  of  an  ointment  con- 
taining usually  sulphur  or  mercury.  The  treatment  takes 
many  weeks,  but  should  be  persevered  in,  or  the  hair  may 
be  permanently  destroyed. 

Impetigo  Contagiosa.— An  acute  contagious  disease  of 
short  duration,  characterized  by  an  eruption  of  vesicles 
and  blebs  which  quickly  become  pustular.  In  a  few  days 
the  blebs  dry  up,  forming  thin  crusts  which,  on  separating, 
leave  light  scars.  Impetigo  usually  attacks  young  and 
weakly  children.  The  eruption  commonly  occurs  on  the 
extremities  or  the  face.  The  contagion  may  be  carried 
by  clothing,  towels,  etc.,  and  the  patient  may  reinfect 
himself  by  scratching. 

The  treatment  consists  in  the  removal  of  the  crusts  by 
bathing  and  the  application  of  an  ointment,  usually  of 
ammoniated  mercury.  The  health  is  reinforced  by  suit- 
able diet,  good  hygiene,  etc. 

The  above  are  descriptions  of  symptoms,  conditions, 


736      SYMPTOMS   AND   CONDITIONS   FREQUENTLY  MET 

and  appearances  associated  frequently  with  different 
forms  of  disease,  all  of  which  are  of  important  signifi- 
cance, and  will  be  met  with  constantly  by  the  nurse  in 
her  work.  It  is  important  that  she  should  be  able  to 
recognize  these  conditions,  to  understand  their  general 
significance,  and  be  familiar  with  the  ordinary  lines  on 
which  they  are  treated.  To  attempt  further  to  describe 
the  symptoms  and  treatment  of  even  the  most  frequently 
encountered  of  the  many  varieties  of  disease  the  nurse  will 
meet  with  is  beyond  the  scope  of  a  practical  manual  of 
nursing,  and,  moreover,  is  obviously  the  work  of  those  es- 
pecially qualified  to  write  on  the  subject. 

In  the  nursing  of  disease  we  must  remember  it  is  the 
symptoms,  rather  than  the  cause,  with  which  we,  as  nurses, 
generally  have  to  do,  and  that  in  all  our  work  the  patient 
himself  is  a  factor  we  can  never  afford  to  lose  sight  of. 
This  is  a  point  on  which  the  teaching  of  the  present  day 
perhaps  neglects  to  lay  sufficient  emphasis;  it  seems, 
therefore,  all  the  more  necessary  that  we  should  make  a 
special  point  of  keeping  the  human  aspect  of  their  work 
constantly  before  our  pupils.  It  is  just  this  that  raises 
our  work  from  drudgery  to  service,  and  makes  it  worthy 
to  be  classed  with  the  great  movements  for  the  good  of 
humanity,  instead  of  simply  a  bread-earning  profession. 


CHAPTER  XXI 
FOOD 

Chemical  Composition — Varieties  of  Food-stuffs — Water — Protein 
—Carbohydrates — Fats — Mineral  Salts — Vegetable  Acids — Condi- 
ments— Summary — Caloric  Value  of  Foods — Calories  in  Diet — Value 
of  a  Mixed  Diet — Digestibility  of  Food-stuffs — Process  of  Digestion 
—Digestive  Juices  and  Their  Action  on  Food-stuffs — Mechanical 
Process  of  Digestion — -Absorption. 

A  PRACTICAL  knowledge  of  cooking  is  really  an  essen- 
tial part  of  a  nurse's  training  if  she  is  to  do  private  nursing, 
and  to  all  nurses  it  is  an  important  part  of  their  equip- 
ment, since,  should  she  remain  in  hospital  work,  a  nurse 
must  sooner  or  later  be  prepared  to  superintend  the  choice 
of  diets  and  the  cooking  of  food-supplies  for  a  number  of 
people,  both  sick  and  well. 

To  do  so  effectively  she  must  understand  the  basis  on 
which  foods  are  selected,  their  individual  value,  their 
economic  use,  and,  especially  in  consideration  of  the  diet 
of  the  sick,  the  various  ways  in  which  food  can  be  prepared 
to  increase  its  digestibility  and  palatableness  and  to  vary 
the  monotony  of  a  restricted  diet. 

By  foods  we  understand  those  substances  which  are 
taken  into  the  body  for  its  growth,  development,  and 
the  repair  of  its  tissues.  Food  also  keeps  up  the  tem- 
perature of  the  body,  and  furnishes  the  motor  power,  or 
energy,  of  its  activities. 

It  is  not  too  much  to  say  that  nothing  makes  so  much 
difference  to  the  average  human  being  as  the  food  he  is 
given;  from  the  patient's  point  of  view  certainly  no  one 
item  of  his  treatment  touches  in  importance  his  meat  and 
drink :  what  it  is,  how  it  is  cooked,  and  in  what  manner  it 
is  served. 

In  selecting  a  diet  a  group  of  facts  have  to  be  con- 
sidered : 

47  737 


738  FOOD 

1.  The  chemical  composition  of  the  food-stuffs. 

2.  Their  value    as    energy-producers,   known   as   the 
"  caloric  "  value. 

3.  Their  digestibility. 

4.  The    condition    of    the    patient's    digestion.     The 
fourth  consideration  will  include  the  patient's  age,  physi- 
cal condition,  and  habit  of  living. 

To  this  group  other  considerations  may  frequently  be 
necessary  to  add,  such  as  whether  a  food  is  in  season,  the 
market  price  of  food,  and  climatic  conditions,  meat  and 
fat,  for  example,  being  required  in  greater  quantities  in  a 
cold  climate,  and  so  forth.  In  the  case  of  certain  diseases 
also  special  dieting  becomes  necessary. 

CHEMICAL  COMPOSITION  OF  FOOD 

We  know  that  all  matter,  however  apparently  solid,  is 
capable  of  being  reduced  into  various  simple  component 
parts,  which  we  know  as  elements  or  bases.  Sugar,  to  take 
a  simple  example,"  is  composed  of  the  three  elements, 
oxygen,  hydrogen,  and  carbon.  The  nature  of  an  ele- 
ment, we  remember,  is  that  it  cannot  be  reduced  to  a 
simpler  substance,  or  decomposed  by  any  known  force. 

Complex  though  the  body  is,  the  cells  of  which  it  is 
composed  are  made  up  of  various  simple  elements,  of 
which  ^the  most  important  are  oxygen,  hydrogen,  carbon, 
and  nitrogen;  other  elements  constantly  present  in  the 
tissues  of  the  body  are  sulphur,  iron,  chlorin,  soda,  mag- 
nesia, lime,  phosphorus,  etc. — in  all,  the  body  represents 
from  15  to  20  different  chemical  elements.  The  mineral 
elements  are  present  in  the  body  as  salts,  that  is  to  say,  in 
combination  with  an  acid;  thus  we  have  chlorid  of  soda, 
phosphate  of  lime,  sulphate  of  magnesia,  and  so  forth.  The 
particular  combination  of  these  elements  found  in  living 
tissues  is  described  as  organic  combination. 

The  body  grows,  develops,  pursues  countless  activities, 
both  functional  and  motor,  and  would,  therefore,  soon 
use  up  the  stock  of  the  necessary  elements  of  which  it  is 
at  birth  composed;  further,  all  activity  causes  some  waste 
of  the  tissues.  It  becomes,  therefore,  necessary  to  fur- 


CHEMICAL  COMPOSITION   OF   FOOD  739 

nish  the  body  with  a  continual  supply  of  each  of  the  above 
elements. 

This  supply  is  obtained  from  the  air  we  breathe  and  the 
food  we  consume. 

Value  of  Oxygen. — Of  all  the  elements  in  the  body,  the 
most  immediately  important  to  life  is  oxygen.  Deprived 
of  oxygen,  even  for  a  few  minutes,  the  body  dies.  Death 
from  want  of  oxygen  we  call  asphyxiation.  Besides 
entering  into  the  composition  of  the  cell,  oxygen  is  neces- 
sary to  the  body  for  two  prime  reasons: 

(1)  Oxygen  is  necessary  for  the  process  by  which  the 
prepared  food  is  split  up  into  its  elemental  parts  and  used 
by  the  body-cell.      This  process  is  similar  to  the  process 
by  which  fuel  is  consumed  in  burning,  and  for  this  reason 
is  known  as  combustion.     As  the  process  cannot  take  place 
without  oxygen  (any  more  than  fuel  can  burn  without 
oxygen),  it  is  often  spoken  of  as  oxidation. 

(2)  By  contact  with  the  oxygen  present  in  the  air- 
cells  of  the  lungs  the  blood  gets  rid  of  a  poison,  carbon 
dioxid,  one  of  the  products  of  oxidation,  which,  if  left  in 
the  body,  quickly  causes  death. 

For  the  body's  supply  of  oxygen  we  depend  oh  the  vol- 
ume continually  taken  up  from  the  atmospheric  air  by 
the  blood  circulating  in  the  walls  of  the  air-cells  of  the 
lungs. 

For  all  the  other  essential  elements  we  depend  upon  our 
food-stuff's. 

It  is  obvious  that  food,  as  we  see  it,  does  not,  except  in  a 
very  few  instances,  such  as  water  and  common  salt,  sug- 
gest in  its  appearance  the  elements  of  which  it  is  composed; 
in  order,  then,  to  supply  the  body  with  the  elements  it 
requires,  and  to  supply  them  in  their  due  proportion,  it  is 
necessary  to  learn  what  various  food-stuffs  contain  these 
elements,  in  what  proportion,  and  in  what  manner  avail- 
able for  the  body's  use. 

Classification. — For  this  purpose  the  food-stuffs  have 
been  classified,  according  to  their  chemical  composition 
in  five  groups: 

1.  Water — hydrogen  and  oxygen. 

2.  Protein — carbon,  hydrogen,  oxygen,  and  nitrogen. 


740  FOOD 

3.  Carbohydrates — carbon,   hydrogen,   and  oxygen,   the 
two  last  in  the  same  proportion  as  in  water. 

4.  Fat  or  hydrocarbon,  also  carbon,  hydrogen,  and  oxy- 
gen, present  as  fatty  acids  (oleic,  palmitic,  stearic),  in  com- 
bination with  glycerin  as  a  base. 

5.  Mineral  salts — lime,  phosphate,   sodium,  iron,   etc., 
as  above. 

Water. — We  derive  water  to  the  greatest  extent  from 
our  drinking-water,  and  from  beverages,  soups,  and  milk. 
It  is  also  present  to  some  extent  in  solid  foods,  as  in  the 
juice  of  meat,  fruit,  and  vegetables.  As  an  essential  to 
the  life  of  the  body  water  ranks  next  in  importance  to 
oxygen. 

Without  food,  but  sufficiently  supplied  with  oxygen  and 
water  and  artificially  protected  from  loss  of  heat,  the  body 
has  been  kept  alive  for  days  and  even  weeks  at  a  time. 
Water  forms  about  two-thirds  of  the  entire  weight  of  the 
body,  and  enters  into  .the  composition  of  every  fluid  and 
solid  tissue  in  the  body.  The  uses  of  water  in  the  body 
are: 

1.  To  regulate  the  body  temperature. 

2.  To  dissolve  solid  substances,  as,  for  example,  food- 
stuffs and  solids  in  urine. 

3.  To  dilute  the  blood  and  other  fluids  of  the  body; 
water  is  the  chief  part  of  all  the  secretions. 

4.  To  dilute  the  poisonous  products  of  oxidation  and 
any  accidental  toxins,  and  to  aid  in  their  elimination. 

5.  It  has  a  definite  use  in  the  process  of  oxidation,  which 
cannot  take  place  without  it. 

Water  does  not  itself  undergo  combustion,  and,  there- 
fore, does  not,  like  other  foods,  supply  energy.  For 
these  purposes,  and  especially  as  a  solvent  and  diluent, 
water  is  more  valuable  in  its  pure  state  than  modified  as 
beverages,  soups,  etc. 

Protein. — Protein  enters  into  the  composition  of  all 
animal  food,  such  as  meat,  fish,  eggs,  milk  and  its  products, 
and  many  vegetable  foods,  especially  the  cereals  (vege- 
tables of  which  we  use  the  seeds  as  food,  oatmeal,  wheat, 
etc.)  and  legumes  (vegetables  of  which  we  use  the  pods, 
as  peas  and  beans).  Such  foods  are  often  described  as 


CHEMICAL   COMPOSITION   OF   FOOD  741 

proteins,  or,  from  the  fact  that  nitrogen  is  obtainable  only 
Srom  protein,  as  the  nitrogenous  foods. 
Protein  is  divided  as  follows: 


Albuminoids: 


f  Albumin,  found  in  white  of  egg. 

Myosin,  "       lean  meat. 

Legumen,  "       legumes. 


Gluten,  cereals. 

Vitellin,  "       yolk  of  egg. 

Caseinogen  and  \  «  -,, 

Lactalbumin       ( 

r>  i  i-     -i       /  Collagen,  found  in  skin  and  tendons. 
Gelatmoids.    (Ossei*  «      bones. 


The  gelatinoids  are  of  less  value  in  the  human  economy 
than  the  albuminoids.  They  are  not  so  readily  digested, 
and  a  large  proportion  passes  from  the  body  unchanged. 
Nitrogenous  foods  also  contain  certain  bodies  known  as 
extractives,  which  impart  flavor  to  the  foods  and  stimulate 
the  appetite  and  the  digestive  secretions.  They  are  with- 
out nutritive  value. 

The  most  important  use  of  protein  is  for  the  repair  of 
the  tissues.  It  is  the  only  food  substance  that  has  this 
property:  we,  therefore,  conclude  that  some  form  of 
nitrogenous  food  is  an  absolute  necessity  to  the  body. 

Whatever  protein  is  not  used  for  the  repair  of  the  tissues 
goes,  in  common  with  the  other  food-stuffs,  to  supply 
energy,  in  the  form  of  heat  and  muscular  power. 

The  carbohydrates  are  derived,  for  the  greater  part,  from 
the  vegetable  foods,  such  as  the  cereals  (wheat,  oatmeal, 
etc.),  the  legumes  (peas  and  beans),  the  tubers  (potatoes, 
etc.),  and  the  pith  of  certain  plants  (sago,  etc.).  Carbo- 
hydrate is  present  in  milk  as  milk-sugar,  and  in  the  form 
of  animal  starch  in  oysters  and  other  mollusks. 

The  carbohydrates  are  divided  into  the  starches  or 
amyloses  and  the  sugars. 

The  amyloses  include  glycogen,  or  animal  starch,  certain 
soluble  gummy  substances,  of  which  dextrin  is  the  most 
important,  and  cellulose,  a  vegetable  carbohydrate,  the 
structural  base  of  all  plants,  which  cannot  be  utilized  by 
the  human  body. 

The  sugars  in  food  are  divided  into  sucroses,  or  cane- 


742  FOOD 

sugars,  and  glucoses,  or  grape-sugars.  Both  sucroses  and 
amyloses  must  be  converted  into  glucose  by  the  action  of 
the  digestive  ferments  before  they  can  be  utilized  by  the 
body.  The  glucoses  can  be  absorbed  without  alteration. 
The  sucroses  include — 

Cane-sugar. 
Beet-sugar. 
Maple-sugar. 
Malt-sugar  (maltose). 
Milk-sugar  (lactose). 

The  glucoses  include — 

Grape-sugar  (dextrose). 
Fruit-sugar  (levulose  or  fructose). 

A  mixture  of  equal  parts  of  grape-sugar  and  fruit-sugar 
is  called  invert  sugar.  Honey  is  a  form  of  invert  sugar. 

Sugar  as  food  is  taken  in  the  form  of  the  different  sugars 
of  commerce,  sweet  fruits,  certain  vegetables,  such  as 
the  tomato  and  cucumber,  and  in  milk  (lactose). 

The  carbohydrates  are  non-nitrogenous  foods,  and 
cannot,  therefore,  be  used  in  the  repair  of  tissue  in  place 
of  the  proteins.  Their  special  use  is  the  production  of 
energy,  especially  in  the  form  of  muscular  power.  What  is 
not  used  for  this  purpose  is  converted  into  fat,  and,  as 
such,  stored  in  the  body.  The  carbohydrates  are  also 
stored  in  the  body  in  the  form  of  glycogen,  or  animal 
starch.  It  is  prepared  from  digested  carbohydrates  by 
the  liver,  and  stored  in  that  organ  for  subsequent  use. 
Some  of  the  glycogen  is  continuously  given  out  in  the  form 
of  dextrose  between  the  meals  to  the  body,  thus  keeping 
up  its  supply  of  heat  and  energy.  A  reserve  supply  is  also 
stored  in  the  liver  for  use  in  an  emergency  when  the  body 
is  deprived  of  food. 

Fats  or  Hydrocarbons. — Fats  are  obtained  both  from 
the  animal  and  the  vegetable  kingdoms.  There  are  three 
varieties  of  fat,  i.  e.,  solid  fat  (stearin),  semisolid  (palmitiri), 
and  liquid  fat  or  oil  (oleiri) .  Animal  fat  is  found  in  meat, 
certain  fish  (salmon,  mackerel,  herrings,  and  cod  livers), 
the  yolk  of  eggs,  cream,  and  butter;  vegetable  fat  in  the 


CHEMICAL    COMPOSITION    OF    FOOD  743 

form  of  oils  (olive  oil,  cotton-seed  oil),  in  nuts,  in  cocoa, 
and  in  chocolate,  and,  to  a  small  extent,  in  the  cereals  and 
some  other  vegetables.  Like  the  carbohydrates,  with  which, 
as  foods,  the  fats  are  to  some  extent  interchangeable, 
their  use  is  to  produce  heat  and  muscular  power  and  to 
supply  the  body  with  fat  or  adipose  tissue.  Except  in  the 
extreme  north,  where  whale  fat  is  one  of  the  principal 
articles  of  diet,  the  carbohydrates  are  more  largely  used. 
They  are  a  less  expensive  variety  of  food,  and,  as  a  rule, 
presented  in  more  digestible  forms.  For  example,  nuts, 
while  containing  a  highly  nutritious  oil,  contain,  at  the 
same  time,  so  much  vegetable  cellulose  that  they  are  a 
highly  indigestible  food.  Fat,  however,  is  considered 
peculiarly  necessary  for  the  development  of  young  tissues, 
where,  from  the  natural  activity  of  young  things,  and  their 
comparatively  rapid  growth  and  development,  a  large 
proportion  of  protein  goes  actually  into  the  repair  of  the 
tissues.  The  best  and  most  easily  digested  form  in  which 
fat  can  be  taken  is  as  cream  or  as  bacon  fat. 

Taken  bulk  for  bulk,  fat  will  produce  twice  the  amount 
of  energy  that  can  be  obtained  from  carbohydrates.  Fat 
is  also  stored  in  the  body  in  the  form  of  fat,  for  use  in 
emergency.  In  cases  of  starvation  the  body  can  consume 
its  own  adipose  tissue,  obtaining  heat  and  muscular  power 
from  its  combustion. 

Mineral  Salts. — The  salts  of  the  various  minerals  are 
found  distributed  through  all  the  food-stuffs,  both  animal 
and  vegetable.  Certain  food-stuffs,  such  as  the  green 
vegetables,  are  valuable  almost  solely  for  their  mineral 
salts  and  contain  little  else  of  nutritive  value.  Some 
green  vegetables  are  rich  in  special  minerals,  such  as 
spinach,  which  contains  an  appreciable  quantity  of  iron. 

The  minerals  help  in  the  building  up  of  the  tissues; 
certain  of  them,  such  as  iron  and  common  salt  (chlorid  of 
soda),  are  continually  present  in  the  blood.  Lime,  in  the 
form  of  phosphate  of  lime,  is  the  basis  of  all  bony  tissue; 
salt  is  found  in  all  the  tissues  of  the  body,  fluid  and  solid; 
from  salt  the  stomach  prepares  the  hydrochloric  acid  of  the 
gastric  juice,  thus  aiding  digestion.  So  important  is 
this  mineral  to  the  body  that,  where  much  is  lost  in  the 


744  FOOD 

cooking  of  food,  more  is  added,  and,  in  addition,  salt  is 
taken  as  a  condiment  (see  below)  with  all  heavy  meals. 

The  mineral  salts  found  in  living  material  are  known  as 
organic  salts;  they  are  usually  more  easily  assimilated 
than  the  inorganic  salts. 

The  importance  of  the  minerals  in  the  human  economy 
is  appreciated  when  we  observe  the  effects  of  a  deficiency 
of  one  or  other  of  the  more  important.  Thus,  when  there 
is  a  deficiency  of  iron,  we  get  the  condition  known  as 
anemia,  with  its  attendant  symptoms;  a  deficiency  of 
phosphate  of  lime  causes  the  bones  to  be  easily  bent  and 
deformed,  the  condition  known  as  rickets,  and  so  forth. 

Organic  Acids. — In  connection  with  the  mineral  salts 
we  must  also  consider  certain  organic  acids,  which,  in 
combination  with  potassium,  forming  the  salts  of  potash, 
have  a  very  marked  influence  on  nutrition.  They  are 
found  in  fruit,  fresh  vegetables,  and  in  milk  that  has  not 
been  sterilized  or  evaporated '  (condensed  milk). 

Deprived  entirely  for  any  length  of  time  of  food  contain- 
ing one  or  other  of  these  acids,  a  group  of  symptoms  known 
as  "  scurvy  "  develops,  which  yields  to  treatment  only 
when  these  acids  are  in  some  form  replaced  in  the  diet. 

The  important  acids  are  as  follows: 

Lactic  acid,  found  in  milk. 

Citric  acid,  found  in  lemons,  oranges,  limes,  tomatoes,  etc. 

Tartaric  acid,  found  in  grapes,  pineapples,  etc. 

Oxalic  acid,  found  in  strawberries,  rhubarb,  etc. 

Malic  acid,  found  in  apples,  pears,  apricots,  gooseberries,  etc. 

Acetic  acid,  found  in  vinegar  and  wine. 

Some  fruits  contain  more  than  one  acid:  Strawberries, 
for  example,  contain  both  oxalic  and  citric  acid. 

The  flavor  of  both  meat  and  vegetable  foods  is  due  to 
the  extractives  already  mentioned,  which  serve  as  a 
stimulant  to  the  appetite  and  to  the  digestive  secretions. 
Artificially,  the  flavor  of  food  is  altered  or  increased  by 
the  use  of  certain  adjuncts,  known  as  condiments.  Pepper, 
salt,  mustard,  vinegar,  spices,  and  essences  are  familiar 
examples  of  condiments  constantly  used  to  make  food 
more  palatable.  Many  of  them  (salt,  mustard)  also 
stimulate  the  gastric  secretions,  thus  aiding  digestion. 


CHEMICAL   COMPOSITION   OF   FOOD 


745 


SUMMARY 
OBTAINED  FROM — 


USES. 


Proteins  or  Nitrogenous 

Foods: 

Chemicalcomposition: 
Hydrogen,  oxygen, 
carbon,  nitrogen; 
with  various  salts, 
sulphur,  iron,  phos- 
phorus, etc. 

Carbohydrates: 

Chemical  composition : 
Oxygen  and  hydro- 
gen (H2O)  and  car- 
bon. 


Fats  and  Oils: 

Hydrocarbons:  Same 
as  carbohydrates. 
Fatty  acids  (oleic, 
palmitic,  and 
stearic)  and  glyc- 
erin. 

Minerals: 

Examples:  Magnesia,' 
soda,  lime,  sulphur, 
etc.,  in  the  form  of 
soluble  salts. 


Organic  Acids: 

Examples :  Acetic, 
citric,  tartaric, 
malic,  oxalic,  and 
lactic,  in  combina- 
tion with  potash. 

Water: 

Chemical  composition: 
Hydrogen  and  oxy- 
gen  (H20). 


Animal:     Meat,    fish,  Repair    of     tissues. 

milk,  cheese,  eggs.  Supply  energy  in 

Vegetable:  Especially  the  form  of  heat 

cereals  and  legumes.  and  muscular 
power. 


Starch:  Cereals,  leg- 
umes, tubers,  pith  of 
plants  (sago) .  Glyco- 
gen  (animal  starch), 
from  oysters  and 
other  mollusks. 

Sugars:  Sugar,  fruit, 
honey,  some  vegeta- 
bles (tomatoes,  etc.), 
and  milk  (lactose) . 

Animal:  Fat  of  meats, 
cream,  butter,  eggs 
(yolk). 

Vegetable:  Oils,  nuts, 
cocoa,  and  choco- 
late. 


Supply  energy,  es- 
pecially muscular 
power;  excess 
converted  into 
fat  and  stored  as 
such;  also  glyco- 
gen,  stored  in  the 
liver.  Can  be 
used  as  spaiers  of 
protein  or  fats. 

Same  as  carbohy- 
drates, valuing 
bulk  for  bulk 
twice  as  much. 
Stored  as  fat  in 
the  tissues. 


In  all  animal  and  vege-  Help    in  the  build- 
table  foods :  A  suffi-       ing  up  and  pre- 
cient  quantity  of  all       serving     of     the 
salts  except  sodium       tissues.      Aid    in 
chlorid,  or  common       digestion, 
salt,  is  supplied  in  an 
ordinary  mixed  diet. 
Common      salt      is 
added  to  all  cooked 
foods. 

Fresh  green  vegetables  Necessary  to  nutri- 
and  fruit;  milk  that       tion. 
has  not  been    sub- 
jected to  high  tem- 
perature; vinegar. 

Drinking-water,  milk,  Regulates  body- 
soups,  beverages;  temperature.  Di- 
the  juice  of  meats,  lutes  all  fluid 
fruits,  and  vegeta-  tissues.  Dilutes 
bles.  poisonous  prod- 

ucts of  oxida- 
tion and  other 
toxins.  Aids  in 
elimination.  Is 
necessary  to  me- 
tabolism. 


746  FOOD 

CALORIC  VALUE  OF  FOOD 

We  see  that  not  only  are  food-stuffs  required  for  the 
repair  of  tissue,  but  that  on  them  the  body  relies  for  the 
production  of  the  energy  necessary  for  its  activities.  By 
the  energy  of  the  body  we  understand  its  heat  and  its  mus- 
cular or  motor  power. 

Above,  we  said  that  the  process  by  which  the  food- 
stuffs, prepared  by  digestion,  were  split  up  into  their  chem- 
ical elements  and  assimilated  by  the  body-cells,  were  similar 
to  the  process  by  which  fuel  was  consumed  in  burning. 
In  the  body  this  process  is  called  combustion  or  oxidation. 
The  relative  value  of  fuels  depends  on  the  amount  of  heat 
engendered  by  their  combustion  and  the  length  of  time 
their  heat  can  be  sustained.  A  further  value  is  reached 
when  we  use  fuel  not  only  to  produce  heat,  but  the  heat 
to  produce  activity  or  power,  as  when  heat  is  used  as  the 
motor  power  of  machinery. 

To  understand  what  we  mean  by  the  caloric  value  of 
any  food  substance  we  must  regard  it  as  the  fuel  used 
to  provide  the  motor  power  of  an  engine.  The  energy  of 
the  body  is  expressed  in  every  one  of  its  activities;  the 
action  of  the  muscles  in  all  the  simple  or  complicated 
acts  of  movement;  the  action  of  the  great  central  nervous 
system  in  controlling  all  the  activities  of  the  body,  of  each 
separate  organ  in  fulfiling  its  own  functional  activity,  of 
each  body-cell  in  assimilating  from  the  food-stuffs  just 
the  element  it  requires  for  its  repair  and  development,  and, 
lastly,  the  activity  of  that  force  we  know  as  the  mind  or 
intellect,  which  works  through  the  medium  of  the  body. 
Just  as  the  different  fuels  have  different  values  as  heat 
and  power  producers,  so,  too,  the  different  foods  vary  on 
this  point.  Some  foods  represent  slow  combustion,  giving 
out  a  steady  supply  of  heat  and  energy  over  lengthened 
periods;  such  foods  we  value  for  their  sustaining  qualities; 
other  foods  are  more  rapidly  oxidized,  and  resemble  a  fuel 
that  flares  up  quickly,  giving  out  a  high  degree  of  heat,  and 
as  quickly  dying  down  again;  the  effect  of  such  foods  is 
to  stimulate  the  body  for  a  short  time.  The  proteins  are 
more  slowly  oxidized  than  the  starches,  and  again  starch 
is  more  slowly  oxidized  than  sugar,  unless  it  has  been  par- 


CALORIC  VALUE  OF  FOOD  747 

tially  dextrinized  by  cooking.  Sugar  is  the  most  rapidly 
oxidized  of  food-stuffs,  and  the  heat  and  energy  produced 
by  its  combustion  are,  in  comparison,  transitory.  Alcohol 
produced  by  the  fermentation  of  sugar  is  more  rapidly  and 
more  completely  oxidized  than  any  other  form  of  food;  it 
is,  therefore,  of  great  value  where  immediate  stimulation 
is  necessary.  Fat  is  a  "  concentrated  fuel  food,"  and,  as 
has  been  said  above,  appears  to  be  particularly  necessary 
for  the  growth  and  development  of  young  tissues. 

Where  we  have  combustion  we  have  also  a  certain  amount 
of  waste,  shown  in  the  residue  or  ash  remaining  after  the 
complete  combustion  of  any  fuel.  In  the  same  way  the 
oxidation  of  food-substances  produces  certain  waste- 
products  in  the  body.  The  ash,  or  residue,  of  protein 
foods  is  known  as  urea;  it  is  excreted  by  the  kidneys  and 
eliminated  from  the  body  in  the  urine.  To  a  much  less 
extent  it  is  also  excreted  by  the  skin  in  the  sweat.  Where 
the  kidneys  fail  in  this  function,  the  body  becomes  rapidly 
poisoned  by  the  accumulation  of  urea  in  the  tissues.  A 
chronic,  imperfect  elimination  of  urea  causes  such  condi- 
tions as  gout,  certain  forms  of  rheumatism,  etc.  The 
acute  condition,  where  no  urea,  or  a  very  small  amount,  is 
eliminated  is  known  as  uremia,  and  is  rapidly  fatal  if 
unrelieved. 

The  waste-products  of  carbohydrate  combustion  form 
carbon  monoxid.  If  allowed  to  accumulate  in  the  tissues, 
this  poisons  the  body  more  rapidly  than  urea,  less  than  five 
minutes  producing  death.  On  contact  with  the  oxygen  in 
the  lungs  carbon  monoxid  leaves  the  body  in  the  form  of 
carbon  dioxid,  or  carbonic  acid  gas.  The  structural  changes 
which  take  place  in  the  body-cells  as  the  result  of  combus- 
tion are  spoken  of  as  metabolism. 

Of  late  years  the  question  of  the  economic  value  of  the 
different  food  elements  as  producers  of  heat  and  energy 
has  received  a  great  deal  of  attention.  It  has  been  made 
practical  by  means  of  an  instrument  known  as  the  bomb 
calorimeter,  to  estimate  the  amount  of  heat  and  power 
produced  by  the  various  food-stuffs  assimilated  by  the 
body.  The  amount  of  heat  and  power  produced  by  the 
complete  combustion  of  any  one  food-stuff  is  spoken  of  as 


748  FOOD 

its  potential  energy.  In  the  scale  used  for  the  comparison 
of  the  potential  energy  of  different  foods  the  unit  or  base 
of  measurement  has  been  named  a  calorie,  or  heat  unit. 
One  calorie  represents  the  amount  of  heat  necessary  to 
raise  the  temperature  of  one  kilogram  of  water  one 
degree  centigrade;  this  amount  of  heat  represents  in  motor 
force  sufficient  power  to  lift  one  ton  1.54  feet.  In  compar- 
ing the  potential  energy  of  different  foods,  we  speak  of  them 
as  valuing  so  many  calories.  The  proteins  and  carbohy- 
drates have,  weight  for  weight,  the  same  caloric  value, 
the  fats  rather  more  than  twice  as  much.  Water  and  or- 
ganic salts,  neither  of  which  undergo  combustion,  have  no 
caloric  value. 

Professor  Atwater  estimates  the  caloric  value  of  food- 
stuffs as  follows: 

1  gm.  protein  (15|  grains)      =     4.0  calories. 
1  gm.  carbohydrate  =     4.0        " 

1  gm.  fat  =     8.9 

Rubner's  scale  is  slightly  higher: 

1  gm.  protein  =     4.1  calories. 

1  gm.  carbohydrate  =     4.1        " 

1  gm.  fat  =     9.3        " 

Both  scales  are  in  use. 

The  caloric  value  of  food  will,  therefore,  depend,  not 
on  the  bulk,  but  on  the  proportion  in  which  the  above 
chemical  elements  are  present.  For  example,  the  white  of 
one  egg,  which  weighs  about  one  ounce,  is  composed  al- 
most entirely  of  albumin  and  water,  the  latter  in  the  pro- 
portion of  86.2  per  cent.;  its  caloric  value  is  14;  the  yolk, 
which  weighs  about  half  an  ounce,  contains  less  water, 
more  protein,  and  about  33  per  cent,  fat,  and  represents 
a  caloric  value  of  58.  A  tablespoonful  of  olive  oil,  which 
is  almost  entirely  hydrocarbon,  furnishes  135  calories. 

Calories  in  Diet. — The  caloric  value  of  food  is  an  impor- 
tant factor  in  preparing  dietaries,  either  for  the  individual 
patient  or  for  large  numbers.  It  is  estimated  that  a 
healthy  man  of  average  weight,  between  130  and  150 
pounds  or  65  to  75  kilograms  (1  kilo  =  2.2  pounds), 


CALORIC  VALUE  OF  FOOD  749 

requires  for  his  daily  consumption  a  diet  that  will  furnish 
about  3000  calories,  generally  divided  as  follows : 

125  gm.  protein  furnishing    500  calories. 

500  gm.  carbohydrate  "        2000       " 

50  gm.  fat  445 

2945        " 

• 

Obviously,  the  amount  of  food  will  be  influenced  by 
many  conditions,  such  as  the  size  of  the  individual,  his 
state  of  health,  etc.,  his  age,  and  occupation.  Less 
food  is  required  if  the  life  is  sedentary,  more  if  there  is 
great  muscular  activity.  A  woman  is  considered  to  require 
about  four-fifths  the  quantity  of  food  required  by  a  man, 
and  children  less  in  proportion  to  their  age,  i.  e.,  between 
the  ages  of  six  and  nine  about  half  as  much,  and  so  forth. 
In  old  age  combustion  takes  place  slowly,  the  body  is 
less  active,  and,  therefore,  less  food  is  required. 

As  a  rule,  in  health  the  appetite  is  the  best  indication  of 
the  amount  of  food  required.  It  is,  however,  important  to 
see  that,  in  the  bulk  desired,  the  proteins,  carbohydrates, 
and  fats  are  in  the  required  proportion. 

An  ordinary  meal  of  meat,  vegetables,  bread,  and 
dessert  represents  the  right  proportions  very  fairly. 

Where  dietaries  have  to  be  made  out  for  large  numbers, 
the  caloric  values  of  the  foods  used  should  be  given  full 
consideration,  in  order  to  provide  meals  of  good  nutritive 
value,  or,  in  other  words,  to  get  the  largest  results  with  a 
minimum  of  outlay.  Those  that  have  the  arranging  and 
ordering  of  such  diets  will  find  a  good  dietary  computer, 
of  which  there  are  several  on  the  market,  an  immense  help. 
One  should  be  chosen  in  which  the  chemical  composition 
of  the  foods  and  their  caloric  value  are  clearly  stated. 

In  dieting  the  sick  at  the  present  day  the  calorific  value 
of  the  foods  is  given  as  much  consideration  as  their  digest- 
ibility. In  acute  illnesses  accompanied  by  much  tissue 
waste  and  active  heat-production,  as  in  many  fevers,  an 
increased  number  of  calories  may  be  necessary,  and,  if 
dieting  is  intelligently  understood,  may  be  administered 
without  increasing  the  bulk  of  the  food  to  be  taken. 
Such  a  diet  is  spoken  of  as  a  high  caloric  diet.  In  other 


750  FOOD 

conditions,  such  as  gout,  arteriosclerosis,  etc.,  it  may  be 
necessary  to  reduce  the  calories  while  giving  the  ordinary 
amount  of  food-stuffs,  and  a  low  caloric  diet  is  selected. 
In  these  circumstances  the  patient  is  usually  weighed  daily, 
and  a  certain  number  of  calories  given  for  each  kilogram 
of  the  patient's  weight.  The  food  must  be  weighed  and 
measured  with  strict  accuracy.  Th§  metric  system  is 
gaining  so  much  in  favor  that  it  is  as  well  to  accustom  the 
pupils  to  its  use  in  weighing  and  measuring. 

Charts  giving  the  caloric  value  of  all  the  varieties  of 
food-stuffs  are  available,  and  pupils  should  be  accustomed 
to  their  use.  Tables  of  the  foods  in  common  use  in  the 
hospital  dietaries  may  be  made  out,  giving  the  quantity 
of  each  required  to  yield  100  calories,  and  are  more  read- 
ily retained  by  the  memory  than  tables  of  more  varying 
numbers. 

Pupils  may  be  given  as  an  exercise  to  find  the  caloric 
value  of  a  meal  or  of  the  whole  diet  of  the  day.  A  food 
table,  giving  the  chemical  composition  of  the  various  food- 
stuffs, is  necessary:  the  materials  are  carefully  weighed,  and 
the  amount  of  protein,  carbohydrate,  and  fat  represented 
in  each  article  of  diet  multiplied  by  either  the  Atwater  or 
Rubner  scale. 

The  tendency  in  many  institutions,  and  in  families  where 
expense  is  a  serious  consideration,  is  to  use  an  excess  of  the 
cheaper  carbohydrate  foods  in  the  place  of  the  proteins  and 
fats.  On  account  of  their  bulk,  these  foods  satisfy  the 
appetite.  For  economic  considerations  experiments  have 
been  made  on  a  large  scale  to  determine  the  value  or 
disadvantages  of  a  purely  vegetable  diet.  The  outcome 
of  such  experiments  goes  to  prove  the  value  of  a  mixed 
diet.  A  purely  vegetable  diet  gradually  produces  a  con- 
dition of  mental  and  physical  inertia,  and  a  lessening  of 
the  powers  of  resistance,  and  is,  therefore,  inappropriate 
where  either  physical  or  mental  work  is  to  be  done.  The 
protein  contained  in  vegetable  foods  is  present  in  much 
smaller  proportion  than  in  animal  food,  and  is  of  a  variety 
less  soluble  and  more  difficult  of  digestion.  To  obtain  a 
sufficient  supply  of  protein  for  the  needs  of  the  body, 
where  active  work  is  required,  from  vegetable  foods, 


DIGESTIBILITY   OF   FOOD  751 

either  alone  or  supplemented  by  milk  and  eggs,  the  bulk 
of  food  required  would  quickly  cause  disorders  of  the 
digestion. 

Other  experiments  have  been  carried  out,  eliminating 
the  carbohydrates  from  the  diet.  The  results  show  a 
decrease  in  muscular  power,  since  muscular  energy  is 
obtained  from  these  foods;  the  physical  endurance  is,  how- 
ever, found  to  be  greater  on  a  protein  diet  than  on  a  vege- 
table one. 

An  excess  of  protein  in  the  diet  leads  to  the  formation  of 
a  larger  proportion  of  urea.  Where  elimination  is  not 
active,  this  creates  a  tendency  to  those  disorders  associated 
with  uric  acid,  such  as  gout  and  rheumatism.  In  mature 
life,  where  the  body  is  less  active  and  less  repair  of  the 
tissues  is  required,  and  in  people  of  sedentary  habits, 
the  proportion  of  protein  in  the  diet  should  be  dimin- 
ished. 

DIGESTIBILITY  OF  FOOD 

A  further  highly  important  consideration  in  estimating 
the  comparative  value  of  different  food  substances  in  a 
diet  is  the  digestibility  of  the  various  foods,  since,  to  quote 
an  old  saying,  "  we  live  not  on  what  we  eat,  but  on  what  we 
digest." 

Process  of  Digestion. — The  work  of  splitting  up  food- 
stuffs into  their  chemical  elements  and  changing  them  into 
soluble  forms,  so  that  they  may  be  absorbed  by  the  lymphat- 
ics and  the  blood,  and  finally  assimilated  by  the  individual 
body  cell,  is  accomplished  by  the  process  we  know  as 
digestion,  which  takes  place  in  the  mouth,  the  stomach,  and 
the  small  intestine. 

As  a  first  step,  solid  foods  must  be  dissolved.  This 
process  is  already  accomplished  in  liquid  foods,  for  which 
reason  liquid  foods  are  a  valuable  form  of  diet  in  condi- 
tions of  enfeebled  digestion. 

In  order  to  be  used  by  the  body,  food  must  further 
undergo  the  following  changes: 

1.  Proteins  (nitrogenous  foods)  must  be  converted  into 
soluble  peptones. 

2.  Carbohydrates  must  be  converted  into  dextrose. 


752  FOOD 

3.  Fats  must  be  either  emulsified  or  split  up  into  fatty 
adds  and  glycerin.  They  are  not  digested  in  the  sense  of 
either  proteins  or  carbohydrates. 

The  above  changes  are  brought  about  by  the  action  of 
the  digestive  juices,  of  which  there  are  three,  each  contain- 
ing one  or  more  active  agents,  known  as  enzymes  or  fer- 
ments. 

The  digestive  juice  in  the  mouth  is  the  saliva,  and  con- 
tains the  ferment  ptyalin.  The  function  of  ptyalin  is  to 
begin  the  digestion  of  the  carbohydrates.  The  starches, 
except  such  as  have  already  been  dextrinized  (see  below), 
are  converted  into  maltose  before  their  final  change  into 
dextrose. 

Substances  soluble  in  water,  such  as  salt  and  sugar,  are 
dissolved  in  the  mouth.  The  saliva  has  no  effect  on  pro- 
teins or  fats.  Food  stays  such  a  short  time  in  the  mouth 
that  the  action  of  the  saliva  is  restricted. 

The  digestive  juice  in  the  stomach  is  the  gastric  juice. 
It  contains  hydrochloric  acid  (about  0.2  per  cent.)  and 
two  ferments,  pepsin  and  rennin. 

The  hydrochloric  acid  provides  the  acid  medium  neces- 
sary for  the  gastric  ferments  to  act,  and  prepares  the 
protein  for  the  action  of  the  ferments;  pepsin  converts  pro- 
tein of  every  variety  into  soluble  peptones;  rennin  coagu- 
lates the  casein  in  milk,  converting  it  into  solid  curds,  which 
are  then  digested  in  the  same  manner  as  other  protein 
foods.  During  the  digestion  of  milk  a  ferment  (lactic 
acid)  is  also  elaborated  from  the  milk  itself,  which  aids  in 
the  process  of  digestion.  Fats  are  melted  and  set  free, 
but  not  otherwise  acted  upon.  The  carbohydrates  remain 
unchanged.  Food  leaves  the  stomach  in  the  form  of  a 
thick,  milky  fluid  known  as  chyme. 

In  the  small  intestine  food  is  acted  upon  by  the  pan- 
creatic juice,  the  bile,  and  the  intestinal  juice.  By  far  the 
greatest  part  of  all  digestion  is  carried  out  in  the  small 
intestine. 

The  pancreatic  juice  excreted  by  the  pancreas  contains 
three  ferments — amylopsin,  trypsin,  and  steapsin. 

Amylopsin  completes  the  conversion  of  the  starches 
into  maltose. 


DIGESTIBILITY   OF   FOOD  753 

Trypsin  completes  the  digestion  of  the  proteins. 

Steapsin  splits  up  fats  into  fatty  acids  and  glycerin,  and 
emulsifies  fats. 

The  bile  excreted  by  the  liver  contains  certain  salts  which 
also  act  on  the  fats,  emulsifying  them  and  splitting  them 
up  into  fatty  acids  and  glycerin,  in  which  forms  they  can 
be  absorbed.  The  bile  is  also  considered  to  act  as  an  in- 
testinal disinfectant,  preserving  the  contents  of  the  in- 
testines from  putrefaction,  and  has  further  the  property 
of  preparing  the  walls  of  the  intestines  for  the  absorption 
of  the  emulsified  fat. 

The  intestinal  juice,  or  succus  entericus,  excreted  in  the 
walls  of  the  small  intestine,  acts  as  a  diluent  to  the  intesti- 
nal contents,  and  contains  a  ferment  (invertiri),  which  it 
is  considered  causes  the  change  of  the  maltoses  (prepared 
from  starch  by  the  ptyalin  and  the  amylopsin)  and  the 
sucroses  into  dextrose,  in  which  form  only  it  can  be  taken  up 
by  the  blood.  The  change,  it  is  supposed,  takes  place 
during  absorption  through  the  intestinal  walls. 

Each  of  the  above  ferments  acts  only  in  that  part  of  the 
digestive  tract  in  which  it  is  produced.  Ptyalin  can  act 
only  in  an  alkaline  medium,  such  as  the  saliva,  its  action  is, 
therefore,  checked  by  the  acidity  of  the  gastric  juice;  pep- 
sin and  rennin  are  only  active  in  an  acid  medium,  such  as 
the  gastric  juice;  their  action  is,  therefore,  checked  by  the 
alkalinity  of  the  digestive  juices  in  the  intestines. 

The  ferments  further  require  that  the  medium  should  be 
at  blood-heat;  iced  drinks,  therefore,  and  ice-cream,  etc., 
by  temporarily  lowering  the  temperature  of  the  gastric 
juice,  delay  digestion  somewhat. 

The  large  intestine  secretes  no  digestive  juices,  but  offers 
a  large  surface  from  which  water  and  food-stuffs  in  the 
soluble  forms  in  which  they  can  be  used  by  the  body  may 
readily  be  absorbed.  As  the  digestive  juices  continue 
their  action  on  the  intestinal  contents  in  the  large  intestine, 
digestion  may,  to  this  extent,  be  said  to  take  place  in  the 
large  intestine.  There  are  no  digestive  juices  in  the  large 
intestine,  however,  to  digest  food-stuffs  introduced  into 
the  alimentary  tract  by  the  rectum.  The  work  of  pre- 
paring the  food-stuffs  must,  therefore,  in  rectal  feeding, 

48 


754  FOOD 

be  performed  outside  the  body;  the  process  is  known  as 
predigestion  or  peptonizing. 

The  undigested  and  indigestible  portion  of  the  food-stuffs 
are  passed  out  of  the  body  as  the  feces. 

Mechanical  Aids. — Digestion  is  also  aided  by  certain 
mechanical  processes.  In  the  mouth  food  is  masticated, 
that  is  to  say,  crushed  and  chewed  and  thoroughly  mixed 
with  the  saliva.  It  is  then  passed  into  the  stomach  by 
the  action  of  swallowing. 

In  the  stomach  food  is  churned  by  the  mechanical  action 
of  the  stomach-walls,  and  passed  forward,  a  small  quantity 
at  a  time,  to  the  intestines  by  a  wave-like,  muscular  move- 
ment of  the  stomach-walls,  known  -as  peristalsis. 

The  peristaltic  action  is  continued  in  the  intestine,  and 
the  food  thereby  forced  gradually  forward  in  the  direction 
of  the  anus.  The  presence  of  bile  is  considered  to  help 
in  this  peristaltic  movement;  if  the  liver  is  sluggish  and 
little  bile  poured  out,  the  peristaltic  action  is  likely  to  be 
weak.  This  is  one  of  the  commonest  causes  of  consti- 
pation. 

Stimulation  of  Juices. — The  digestive  juices  are  stimu- 
lated by  the  presence  of  food.  Recent  research  has  also 
shown  that  both  the  quantity  and  the  quality  of  the  juices 
are  affected  by  the  different  kinds  of  food-stuffs  and  by  the 
individual  liking  for  the  food  taken.  Thus,  food  eaten  with 
an  appetite  is  considered  to  be  more  easily  digested  than 
the  same  food  taken  unwillingly  or  with  indifference. 
This  is  an  important  point  for  nurses  to  remember,  since 
the  appetite  may  be  tempted  by  dainty  service,  quiet  and 
pleasant  surroundings,  and  by  offering  just  the  right  quan- 
tity at  the  right  time.  Slovenly  service,  disorderly  sur- 
roundings, unpunctuality,  or  an  overheaped  plate  may 
affect  even  a  healthy  appetite.  Where  possible,  the 
individual  taste  should  be  consulted,  and,  even  where  the 
diet  is  restricted,  pains  should  be  taken  to  vary  it  as  much 
as  possible. 

The  fact  that  the  quantity  and  quality  of  the  digestive 
juices  varies  with  the  different  varieties  of  food-stuffs 
demonstrates  further  the  value  of  a  well-balanced,  mixed 
diet.  The  supply  of  all  secretion  depends  largely  on  the 


ABSORPTION    OF   FOOD  755 

demand,  and  the  same  holds  true  of  the  secretion  of  the 
digestive  juices.  If,  for  example,  there  is  but  little  demand 
for  protein  digestion,  less  gastric  juice  is  secreted,  and  the 
proportion  of  the  composition  is  somewhat  altered.  This 
should  be  remembered  in  adding  to  a  patient's  diet  any 
food-stuffs  that  have  been  withheld,  as,  for  instance,  in 
reintroducing  protein  foods  after  a  patient  has  been  kept 
for  a  time  exclusively  on  carbohydrate  foods;  the  change 
should  always  be  effected  gradually. 

The  sight  and  smell  of  food,  when  pleasant  to  the  appe- 
tite, stimulate  the  flow  of  the  saliva,  and  probably  of  the 
other  digestive  juices.  That  this  fact  is  widely  accepted 
we  know  from  the  homely  saying  that  good  food  makes  the 
mouth  water. 

The  temperature  of  the  food  affects  the  secretion  of  the 
gastric  juice.  The  presence  of  food  in  the  stomach  causes 
the  dilatation  of  the  blood-vessels  in  the  walls  of  the  stom- 
ach, and  a  large  increase  in  the  quantity  of  blood.  It  is 
estimated  that  nine  times  the  ordinary  amount  of  blood 
is  present  in  the  walls  of  the  stomach  during  digestion. 
Hot  fluids  help  in  the  dilatation  of  the  vessels,  and  so  stim- 
ulate digestion;  ice-cold  drinks  and  foods,  by  contracting 
the  more  superficial  vessels,  are  considered  to  delay 
digestion  somewhat,  as  well  as  by  arresting  the  activity 
of  the  ferments,  as  noticed  above.  On  the  other  hand, 
cold  is  held  to  stimulate  the  peristaltic  action  of  the 
stomach. 

ABSORPTION  OF  FOOD 

The  absorptive  powers  of  the  different  parts  of  the  diges- 
tive tract  vary  considerably.  A  very  small  amount  of 
converted  carbohydrates,  alcohol,  and  common  salt  may 
be  absorbed  in  the  mouth;  in  the  stomach  the  same,  to- 
gether with  a  small  proportion  of  peptones  and  mineral 
salts,  are  absorbed  without  undergoing  intestinal  digestion. 
In  the  small  intestines  foods  of  every  sort  are  absorbed, 
especially  the  emulsified  and  saponified  fats,  which  are 
taken  up  by  the  lymphatics  in  the  walls  of  the  small  in- 
testine (the  lacteals);  lastly,  the  large  intestine  acts  as  a 
reservoir  from  which  the  remainder  of  the  food-stuffs 
and  water  is  absorbed. 


750  FOOD 

With  the  exception  of  the  fats  taken  up  by  the  intestinal 
lymphatics,  the  food-stuffs  are  collected  from  the  super- 
ficial blood-vessels  of  the  alimentary  tract  by  the  portal 
vein,  and  carried  directly  to  the  liver;  thence  to  the  vena 
cava,  and  so  finally  distributed  through  the  whole  arterial 
system.  The  liver,  besides  taking  from  the  blood  what  is 
necessary  for  the  use  of  the  individual  cells  of  the  liver 
itself,  also  stores  up  a  certain  amount  of  the  digested 
carbohydrates,  which  it  converts  into  glycogen,  or  animal 
starch.  As  glycogen  is  insoluble,  it  is  converted  back 
into  dextrose,  when  it  is  given  back  to  the  blood. 

The  fats  absorbed  by  the  lacteals  also  finally  reach  the 
general  circulation  through  the  thoracic  duct,  a  lymphatic 
vessel  which  collects  the  contents  of  the  intestinal  lymph- 
atics and  passes  them  into  the  general  circulation  at  the 
junction  of  the  left  subclavian  and  left  internal  jugular 
veins. 

The  comparative  digestibility  of  the  various  food-stuffs 
is,  for  convenience,  reckoned  by  the  length  of  time  that 
the  foods  take  completely  to  leave  the  stomach.  A  full 
meal  of  mixed  ingredients  takes  about  four  hours  to  leave 
the  stomach.  A  light  meal  of,  for  example,  tea  or  coffee, 
bread,  and  eggs,  should  have  left  the  stomach  in  from  one 
and  a  half  to  two  hours.  Tables  may  be  found  in  most 
books  on  dietetics  giving  the  comparative  digestibility 
of  the  common  varieties  of  foods. 

Conditions  Disturbing  Digestion. — Many  conditions 
disturb  the  digestion  to  a  greater  or  less  extent.  A  meal 
should  not  be  taken  immediately  after  prolonged  physical 
exertion,  nor  should  exercise  be  taken  immediately  after 
a  meal.  On  the  other  hand,  exercise  an  hour  or  two  after 
a  meal  promotes  absorption.  Very  violent  exercise  im- 
mediately after  a  meal  arrests  digestion  altogether,  causing 
severe  headache,  vomiting,  and  sometimes  cardiac  failure. 
Nervous  irritation,  excitement,  or  strong  emotion  will 
materially  upset  the  digestion,  while  congenial  company 
and  pleasant  surroundings  actually  promote  digestion. 
Bathing  disturbs  digestion  by  diverting  the  necessary 
blood-supply  from  the  stomach,  and  should  not  be  prac- 
tised after  a  meal.  Digestion  during  sleep  is  continued 


ABSORPTION   OF   FOOD 


757 


slowly ;  the  last  meal  of  the  day  should,  therefore,  be  given 
time  to  digest  before  bedtime.  The  stomach  should  be 
allowed  to  rest  for  a  time  before  each  meal ;  for  this  reason 
the  habit  of  eating  between  meals  is  pernicious. 


SUMMARY  OF  THE  DIGESTIVE  PROCESSES 


Mouth 


Stomach . 


Intestines. 


Saliva : 
Alkaline. 


Gastric  juice: 
Acid. 


Pancreatic  juice: 
Alkaline. 


Intestinal  juice: 

Alkaline. 
Bile: 

Alkaline. 


Ptyalin:  Converts  starches  into 
maltose  (sugar  and 
salt,  etc.,  are  dis- 
solved) . 

Pepsin:  Converts  proteins  into 
soluble  peptones. 

Rennin:  Coagulates  casein, 
forming  curds. 

(Fats  are  set  free  and  melted.) 

Amylop-  Completes  digestion  of 
sin:  starches;  dissolves 
cellulose. 

Trypsin :  Completes  digestion  of 
proteins. 

Steap-  Splits  fats  into  fatty 
sin:  acids  and  glycerin. 
Emulsifies  fats. 

Invert-  Changes  sucroses  into 
ase :  dextrose. 

Bile  Emulsify  fats.  Pre- 
salts:  pare  the  walls  of  the 
intestines  for  absorp- 
tion of  fats.  Avert 
putrefaction. 


CHAPTER  XXII 
THE  PREPARATION  OF  FOOD 

Effect  of  Cooking  on  Proteins — Carbohydrates — Fats — Milk — 
Cream — Skimmed  Milk — Whey — Curds — Dilution — Fermentation- 
Heating — Predigestion — Flavoring — Milk  as  Infants'  Food — Modi- 
fication— Signs  of  Indigestion  of  Milk — Eggs — Gruels — Meat  Broths 
and  Extracts — Water — Beverages. 

THE  process  of  digestion  is  materially  helped  by  the 
manner  in  which  raw  food-stuffs  are  prepared  and 
cooked. 

To  take  the  most  obvious  example,  we  do  not  use  the 
cereals  as  food  in  the  form  of  oats  and  wheat,  as  we  find 
them  growing.  The  grain  is  first  removed  from  the  husk, 
then  ground  and  rolled,  thus  producing  flour  and  meals, 
which  are  easy  to  cook,  and  when  cooked,  are  readily 
acted  upon  by  the  digestive  ferments,  and  contain  com- 
paratively little  material  that  cannot  be  used  by  the 
body. 

The  objects  of  the  processes  we  know  as  cooking  are, 
by  the  exposure  of  food-stuffs  to  certain  temperatures,  by 
the  chemical  action  of  various  alkalis  and  acids,  and  by 
combination  with  other  food-stuffs,  extractives,  or  con- 
diments, to  render  food  more  palatable  and  more  easily 
digested  and  absorbed  by  the  body. 

Exposure  of  raw  food-stuffs  to  heat  is  the  simplest  form 
of  cooking;  heat,  combined  with  moisture,  has  the  general 
effect  of  softening  hard  or  tough  tissues,  such  as  meat  fiber 
and  the  indigestible  cellulose  of  plants,  and  making  them 
more  readily  broken  up  and  dissolved  by  the  digestive 
processes.  On  the  different  varieties  of  food-stuffs  heat 
and  moisture  produce  important  chemical  changes,  on  the 
understanding  of  which  the  whole  principles  of  cooking 
are  based. 

758 


THE   PREPARATION    OF    FOOD 


759 


760  THE    PREPARATION    OF   FOOD 

PROTEINS 

The  albuminoids  are  dissolved  in  cold  water  and  coag- 
ulated by  heat  or  acids.  For  example :  If  the  white  of  an 
egg  (egg-albumen)  is  stirred  in  cold  water,  it  is  dissolved; 
if  it  is  dropped  into  hot  water,  it  becomes  coagulated  and 
solid;  casein,  the  principal  albumin  of  milk,  is  changed  into 
a  solid  curd  on  the  addition  of  an  acid,  such  as  rennet. 

The  albumins  of  meat  are  affected  in  the  same  way. 
If  raw  meat  is  placed  in  cold  water,  the  albumins  are  dis- 
solved and  the  juices  drawn  out  into  the  water;  if  plunged 
into  hot  water,  the  albumins  are  coagulated  and  seal  up 
the  blood-vessels,  thus,  keeping  the  juices  in  the  meat. 
Thus,  if,  we  want  nourishing  broths  or  stews  we  put  the 
meat  in  cold  water  and  heat  it  slowly;  if  the  meat  itself 
is  to  be  the  nourishing  part,  we  expose  it  at  once  to  a  high 
temperature,  as  in  roasting,  broiling,  or  baking.  The 
fibrin  of  meat  is  not  soluble  either  in  cold  or  hot  water. 
We,  therefore,  eliminate  fibrin  entirely  where  the  digestion 
is  weak,  or  divide  it  up  very  finely,  as  in  minces. 

The  gelatinoids  are  drawn  from  bone,  skin,  and  tendon 
by  prolonged  boiling,  and  are  not  soluble  in  cold  water. 
Although  not  valuable  as  food  in  the  same  sense  as  albu- 
mins, soups  made  from  bone-stock  in  this  way  are  rich  in 
minerals,  especially  phosphate  of  lime,  which  is  found 
principally  in  bone. 

Raw  meat  is  insipid  and  flavorless.  Exposure  to  heat 
brings  out  the  distinctive  flavor  of  meats,  as  does  also  the 
addition  of  common  salt.  It  is  for  this  reason  that  the 
beef-juice  of  slightly  cooked  meat  is  more  palatable  than 
that  expressed  from  raw  beef,  and  still  more  so  if  salt  is 
added. 

CARBOHYDRATES 

The  starch  in  vegetable  foods  is  inclosed  in  a  capsule 
of  cellulose,  which  must  be  broken  down  before  the  starch 
can  be  acted  upon  by  the  digestive  ferments.  Exposure  to 
heat  causes  the  starch-grains  to  swell,  so  that  the  cellu- 
lose is  burst  and  the  grains  of  starch  set  free,  to  be  acted 
upon  by  the  digestive  ferments.  Soaking  in  cold  water 
will  separate  the  starch  grains  and  thus  prevent  lumping 
while  they  are  cooking. 


FATS  7G1 

We  saw  above  that  starch  must  be  converted  into 
dextrose  before  it  is  used  by  the  body.  This  process  can 
be  partially  accomplished  in  cooking,  either  by  prolonged 
exposure  to  heat,  or  by  the  addition  of  certain  ferments, 
such  as  diastase  of  malt,  which  have  the  property  of 
dextrinizing  starch.  Farinaceous  foods,  Mellin's  food,  and 
other  proprietary  foods  owe  their  value  to  this  process. 

Cane-sugar  (sucrose}  is  changed  to  grape-sugar  (dextrose, 
one  of  the  glucoses')  by  prolonged  exposure  to  heat.  As 
grape-sugar  is  only  half  as  sweet  as  cane-sugar,  much  of  the 
sweet  taste  is  thus  lost.  For  this  reason  sweetening  is 
usually  added  to  dishes  toward  the  end  of  cooking. 

Cereals  are  cooked  in  a  large  proportion  of  boiling  water, 
with  the  addition  of  salt,  which  brings  out  the  flavor. 
Where  the  meal  is  fine  or  flour  is  used,  the  grains  should 
always  be  separated  by  being  mixed  first  in  cold  water  to 
prevent  lumping.  Cereals  should  be  cooked  slowly  and 
very  thoroughly. 

Vegetables. — "  All  plants  used  for  food  except  grains 
and  fruit "  (Farmer).  One  of  the  chief  objects  in  cooking 
vegetables  is  to  break  down  and  soften  the  cellulose,  which 
is  the  structural  base  of  all  plants.  Although  cellulose 
is  not  used  by  the  body,  it  is  valuable  as  supplying  bulk. 
Vegetables  are  cooked  in  boiling  water  to  which  salt  is 
added.  Salt  brings  out  flavors  and  coagulates  the  legu- 
men  in  peas,  beans,  and  lentils. 

FATS 

Cooking  has  no  effect  on  the  digestibility  of  fats  and 
oils. 

In  good  cooking  the  valuable  mineral  salts  are  preserved; 
in  careless  and  unintelligent  cooking  they  are  frequently 
lost,  and  some  of  the  nutritive  value  of  the  food  is  thus 
wasted. 

On  the  above  facts  the  principles  which  govern  the  cook- 
ing of  foods,  the  temperature  necessary,  the  time  required, 
etc.,  are  based.  To  carry  these  principles  further  and 
study  their  effects  in  the  preparation  of  all  the  various 
food-stuffs  we  consume  is  beyond  the  scope  of  a  general 
text-book,  and  belongs  rather  to  a  full  course  in  cooking. 


762  THE   PREPARATION   OF   FOOD 

Certain  simple  forms  of  food  it  is,  however,  from  the  begin- 
ning of  her  training,  part  of  a  nurse's  duties  to  prepare 
and  administer;  It  seems  essential  that  she  should  un- 
derstand the  comparative  importance  of  these  foods,  their 
value  in  the  human  economy,  and  the  different  forms  of 
preparation  by  which  they  may  be  made  appetizing  and 
most  readily  digestible. 

In  the  large  majority  of  illnesses  the  digestive  processes 
are  deranged,  and  it  becomes  necessary  to  provide  the 
body  with  food  in  those  forms  in  which  it  can  be  most 
readily  digested.  It  is  essential  that  the  diet  should  in- 
clude all  five  food  elements  in  a  proper  proportion.  At  the 
same  time,  as  with  rest  in  bed  the  body  has  no  motor  activ- 
ity to  perform,  a  much  smaller  quantity  of  food  is  required. 
To  give  an  ordinary  quantity  of  solid  food  to  a  patient 
confined  to  bed  is  likely  to  cause  some  of  the  disorders 
of  deficient  elimination.  The  simple  forms  of  food  to 
which  we  shall  confine  ourselves  are  milk,  eggs,  beverages, 
soups,  and  gruels,  foods  which  constitute  the  entire  diet  of 
the  majority  of  acute  cases. 

MILK 

Of  all  the  various  food-stuffs,  milk  is  the  most  valuable 
to  man,  and  for  the  following  reasons: 

1.  It  contains  all  five  food  elements  in  their  proper 
proportion;  for  this  reason  it  is  often  called  the  perfect 
food. 

2.  It  is  generally  procurable. 

3.  It  is  comparatively  inexpensive. 

4.  Usually  it  is  easily  digested. 

In  many  of  the  large  agricultural  districts  of  the  world 
milk  is  the  principal  article  of  diet,  and  with  cheese  and 
eggs  the  only  animal  food  taken;  it  is  also,  as  we  know, 
the  natural  and  sole  food  of  infants  and  all  young  mam- 
mals, and  an  important  article  in  the  diet  of  children  dur- 
ing the  years  of  their  most  rapid  development. 

Milk  as  a  sole  article  of  diet  is  not  suitable  for  people 
leading  active  lives;  to  obtain  from  milk  alone  the  quantity 
of  protein  necessary  for  a  man  in  active  work  as  much  as 
four  quarts  of  milk  would  be  required,  at  the  same  time 


MILK  763 

he  would  be  taking  too  much  fat  and  too  small  an  amount 
of  carbohydrates.  The  consequence  of  such  a  diet  would 
be  an  undue  accumulation  of  adipose  tissue  and  a  decrease 
in  muscular  energy. 

In  the  agricultural  districts  just  mentioned  the  extra 
protein  is  taken  chiefly  in  the  form  of  cheese,  and  the 
carbohydrates  as  potatoes  and  bread.  In  the  diet  of  the 
sick  an  increase  of  proteins,  if  desired,  is  usually  given  in  the 
form  of  eggs,  especially  the  easily  digested  whites  of  eggs, 
and  meat  broths,  and  the  carbohydrates  in  the  forms  of 
gruels,  barley  water,  or  simple  farinaceous  foods. 

The  chemical  composition  of  cows'  milk  is,  on  an  average : 
Fat,  4  per  cent. ;  carbohydrates,  4.5  per  cent.;  protein,  4  per 
cent.;  mineral  salts,  0.7  per  cent.;  and  water,  about  87 
per  cent.  The  proportion  in  which  the  fats,  proteins,  and 
carbohydrates  are  required  in  the  diet  of  an  adult  doing 
active  work  are  as  fat,  2;  protein,  4,  and  carbohydrates,  18. 
Oysters  and  similar  shell-fish  are  the  only  other  food- 
substances  which  contain  the  five  elements  in  something 
the  same  proportion  as  milk.  For  this  reason  they  are, 
when  taken  raw,  on  account  of  their  easy  digestion,  a  valu- 
able food  in  the  sick-room.  They  cannot,  however,  be 
taken  in  sufficient  quantity  to  take  the  place  of  milk,  even 
if  their  price  did  not  make  them  a  much  more  expensive 
food.  The  chemical  composition  of  an  oyster  is,  on  an 
average:  Fat,  1.1  per  cent.;  carbohydrates,  in  the  form  of 
animal  starch  or  glycogen,  3.3  per  cent.;  protein,  6.1  per 
cent.;  mineral  salts,  0.9  per  cent.,  and  water,  88.3  per 
cent. 

Indigestibility  of  Milk. — A  very  little  experience  is 
needed  to  show  that  milk,  as  obtained  from  the  cow,  can- 
not be  digested  by  infants  or  by  a  large  proportion  of 
sick  or  convalescent  persons.  An  exclusive  diet  of  milk 
is  apt  to  produce  gastric  irritation,  a  coated  tongue, 
nausea,  constipation,  and  biliousness,  or,  less  frequently, 
diarrhea;  often  the  milk  cannot  be  taken  in  sufficient 
quantities  for  purposes  of  nutrition.  Many  persons  also 
who,  when  in  health,  drink  milk  freely,  when  ill  dislike  the 
taste. 

At  the  same  time  there  is  no  perfect  substitute.     An 


764  THE   PREPARATION    OF   FOOD 

important  part  of  our  work  is  then  to  find  out  in  what  way 
the  disadvantages  of  milk  as  a  diet  for  the  sick  can  be 
overcome. 

The  principal  cause  of  the  indigestibility  of  milk  is  the 
protein  caseinogen,  which,  by  action  of  the  ferment 
rennin,  is  converted  in  the  stomach  into  solid  curds. 
Where  the  digestion  is  enfeebled,  these  curds  are  frequently 
found  impossible  of  digestion. 

The  biliousness,  which  is,  an  occasional  symptom  where 
the  diet  is  exclusively  of  milk,  is  commonly  caused  by  the 
large  proportion  of  fat. 

These  disadvantages  may  be  mitigated  in  several  ways : 

1.  Milk  may  be  split  up,  and  the  parts  that  disagree  with 
digestion  either  altered  or  left  out. 

Cream. — If  we  take  the  cream  alone,  we  obtain,  in 
the  same  bulk,  a  higher  proportion  of  fat  (from  10  to 
30  per  cent.,  instead  of  4  per  cent.),  while  the  proteins, 
carbohydrates,  and  salts  remain  about  the  same.  Cream, 
therefore,  is  used  with  advantage  where  emaciation  makes 
the  use  of  an  excess  of  fat  necessary,  1  ounce  of  rich 
cream  containing  as  much  fat  as  6  or  8  ounces  of  whole 
milk.  Rich  cream,  being  largely  pure  fat,  has  consequently 
a  very  high  caloric  valve.  This  makes  it  a  valuable  food 
where  the  greatest  results  are  desired,  with  the  least  amount 
of  work  for  the  digestive  organs. 

Skimmed  or  Fat-free  Milk. — Skimmed  milk  is  milk  with 
the  fat  removed,  the  protein,  carbohydrates,  and  salts  re- 
maining. It  is,  therefore,  well  borne  in  many  cases  of 
intestinal  indigestion,  and  in  jaundice,  where  the  bile  is 
decreased  or  absent,  in  which  condition  the  fats  are  not 
well  borne  (Chap.  XXI). 

Whey. — Whey  is  milk — as  a  rule,  skimmed  milk — from 
which  the  casein  has  been  removed,  usually  by  the  action 
of  rennet.  It  contains  no  fat  or  casein,  1  per  cent,  protein 
in  the  form  of  lactalbumin,  and  the  full  proportion  of 
carbohydrates  and  salts.  The  lactalbumin  is  the  same  as 
the  albumin  found  in  the  blood,  and,  therefore,  readily 
assimilated.  Whey  is  often  of  great  value  where  the  diges- 
tion is  seriously  impaired,  especially  in  the  feeding  of 
young,  feeble  infants. 


MILK  765 

The  curds  obtained  by  this  process,  which  contain  the 
casein,  together  with  carbohydrates  and  salts,  form  an 
agreeable  change  in  an  exclusive  milk  diet,  but  are  not 
suitable  where  the  digestion  of  proteins  is  difficult. 

Buttermilk. — Buttermilk  is  the  sour,  acid  fluid  sepa- 
arated  from  sour  milk  or  cream  by  churning,  by  which  proc- 
ess the  fat  is  removed  in  the  form  of  butter.  In  chemical 
composition  buttermilk  closely  resembles  skimmed  milk, 
and  is,  for  the  same  reasons,  useful  in  cases  of  intestinal 
disorders.  The  sour  taste  is  due  to  the  bacterial  activity 
that  has  caused  the  souring  or  ripening  of  the  milk.  It  is 
often  appreciated  where  sweet  milk  is  disliked.  Butter- 
milk has  a  decided  laxative  effect,  and  is,  therefore, 
not  suitable  in  conditions  where  diarrhea  exists,  and  is, 
on  the  other  hand,  peculiarly  serviceable  in  conditions 
accompanied  by  biliousness  or  obstinate  constipation. 

2.  The  dilution  of  milk  with  hot  water  or  with  one  of  the 
carbonated  table  waters  (Apollinaris,  Vichy,  seltzer,  etc.) 
is  frequently  the  simplest  means  of  increasing  the  digesti- 
bility of  milk.     The  latter  not  only  give  to  the  milk  a  re- 
freshing, agreeable  taste,  but  have  the  effect  of  separating 
the  particles  of  casein,  which  consequently  solidifies  in 
less  dense  curds. 

Milk  may  also  be  diluted  by  being  mixed  with  thin 
gruels,  toast,  bread-crumbs,  or  crackers.  This  increases 
the  nutritive  value  of  the  diet,  and  has  also  the  effect  of 
causing  the  casein  to  form  in  lighter  curds.  Gruels  should 
not  be  given  where  there  is  any  tendency  to  diarrhea. 

3.  Lessening  Acidity. — Substances    may   be  added  to 
the  milk  to  increase  its  digestibility. 

An  alkali,  such  as  lime-water  or  bicarbonate  of  soda,  by 
lessening  the  acidity  of  the  medium,  restricts  the  curdling 
action  of  the  rennin  on  the  casein,  and  causes  the  curds 
to  form  in  much  smaller,  lighter  masses,  resembling  more 
the  curds  of  natural  human  milk.  Lime-water  is  usually 
added  in  the  proportion  of  1  part  lime-water  to  from  6  to  12 
parts  of  milk ;  bicarbonate  of  soda,  in  the  proportion  of 
about  1  grain  to  the  ounce.  The  latter  is  used  largely  in 
infant-feeding. 

The  addition  of  common  salt  is  frequently  observed  to 


766  THE   PREPARATION    OF   FOOD 

aid  in  the  digestibility  of  milk.  We  saw  that  the  stomach 
uses  common  salt  in  the  manufacture  of  the  hydrochloric 
acid  of  the  gastric  juice:  patients  who  are  kept  for  long 
on  an  exclusively  milk  diet  frequently  suffer  from  lack  of 
the  salt. 

4.  Fermentation. — Fermentation  is  the  disorganization 
and  oxidation  of  the  carbohydrates  (Gould). 

Among  the  primitive  races  of  the  East  the  process  of 
fermentation  has  been  known  for  ages  as  a  means  of  pre- 
serving milk  and  increasing  its  digestibility.  At  the 
present  day  fermented  milk  is  found  invaluable  in  many 
severe  gastric  disorders,  especially  in  chronic  varieties, 
and  rarely  fails  to  be  retained. 

Koumiss,  matzoon,  and  kefir  (see  Recipes)  are  the  forms 
of  fermented  milk  in  use;  they  differ  but  slightly  from  each 
other  in  composition.  In  the  East  mares'  or  asses'  milk 
were  commonly  used;  in  this  country  cows'  milk  is  pre- 
ferred, and  is  more  readily  attainable. 

5.  Heating. — Hot  milk  frequently  appears  more  easily 
digested  than  cold,  probably  from  the  stimulating  effect 
of  hot  fluids  on  the  gastric  secretions.     Care  must  be  taken 
not  to  bring  the  milk  to  a  higher  temperature  than  155°  F., 
or  the  albumins  will  be  coagulated  and  rendered  less  easy 
of  digestion.     (See  Pasteurization  and  Sterilization.) 

6.  Predigestion. — By  the  addition  of  a  ferment  resem- 
bling the  pepsin  of  the  gastric  juice,  proteins  may  be  con- 
verted into  soluble  peptones.     The  process  is  frequently 
used  for  the  predigestion  of  the  protein  in  milk,  in  cases 
where  the  digestion  is  greatly  impaired,  and  for  rectal  feed- 
ing.    Several  preparations  for  the  predigestion  or  pepton- 
izing  of  milk,  etc.,  are  on  the  market  (see  Recipes),  all 
having  for  their  object  the  conversion  of  proteins  into  sol- 
uble peptones. 

If  milk  is  completely  peptonized,  it  has  a  peculiarly 
bitter  taste;  this  is  objectionable  except  occasionally, 
in  special  cases,  such  as  acute  catarrhal  jaundice,  where 
the  patient  frequently  craves  bitter-tasting  foods.  The 
digestive  process  can  be  arrested  at  the  desired  point, 
either  by  placing  the  milk  on  ice  or  by  bringing  it  quickly 
to  the  boiling-point.  Like  the  ferments  in  the  digestive 


MILK  767 

juices,  the  artificial  peptonizing  agents  can  act  only  at 
certain  temperatures,  and  in  a  medium  of  a  certain  degree 
of  acidity  or  alkalinity.  To  obtain  accuracy  on  these 
points  the  directions  which  accompany  the  various  pepton- 
izing preparations  must  be  carried  out  exactly. 

7.  Flavoring. — Quite  frequently  the  taste  of  milk  is 
objected  to;  the  difficulty  may  be  overcome  by  flavoring 
the  milk  with  weak  freshly  made  tea  or  coffee,  cocoa, 
chocolate,  etc.;  with  the  two  latter  the  nutritive  value  of 
milk  is  increased. 

Milk  may  also  be  given  in  solid  form,  as  junket,  blanc- 
mange, or  as  milk  jelly  (see  Recipes).  These  forms  are 
frequently  prescribed  in  cases  of  paralysis  of  the  soft 
palate  (a  common  sequela  of  diphtheria),  as  solids  are 
then  more  readily  swallowed  than  fluids.  Ice-cream  is  also 
valuable,  flavored  with  simple  essences  or  fresh  fruit. 
It  is  too  rich  in  fat,  however,  to  be  taken  in  large  quantities. 
Where  a  milk  diet  is  continued  over  long  periods,  as,  for 
example,  in  cases  of  acute  nephritis,  much  ingenuity  is 
required  to  prevent  the  food  becoming  hopelessly  monot- 
onous. It  may  be  altered  in  any  of  the  ways  just  sug- 
gested, and  the  form  varied  at  the  different  hours  of 
nourishment. 

Example  of  a  milk  diet  for  the  day: 

7  A.  M.     Cup  of  milk  flavored  with  hot  weak  tea  or  coffee. 
10  A.  M.     Glass  of  milk  with  Vichy,  etc. 
1  P.  M.     Dish  of  curds  and  whey  with  cream.    Varied  with 

blanc-mange  or  ice-cream. 
4  P.  M.     Cup  of  milk  flavored  with  cocoa. 
7  P.  M.     Glass  of  warm  milk  or  milk  and  hot  water. 

Frequently  a  light  carbohydrate  diet  is  combined  with 
the  milk  diet,  and  milk-toast,  gruels,  and  farinaceous 
puddings  may  be  used  to  give  variety,  and  light  cakes,  such 
as  lady-fingers  or  simple  crackers,  added  as  dainties. 
Another  method  of  flavoring  milk  or  cream  is  to  serve  it 
as  a  soup,  flavored  with  a  small  amount  of  some  well- 
cooked  vegetable,  choosing  those  which  are  least  rich  in 
proteins,  such  as  tomatoes,  asparagus,  spinach,  or  onions, 
and  season  with  butter  and  salt.  Pepper  must  be  avoided 


768  THE   PREPARATION    OF   FOOD 

where  the  kidneys  are  irritated  or  the  digestive  organs 
impaired. 

Where  milk  is  given  as  an  additional  nourishment  with 
a  mixed  diet,  it  should  not  be  taken  with  a  heavy  protein 
meal,  since  the  casein  in  itself  taxes  the  digestion  con- 
siderably. It  is  best  taken  with  a  cereal  or  a  farinaceous 
pudding,  or  by  itself  with  a  cracker,  as  a  light  luncheon 
between  meals. 

Milk-punches  or  white  wine  whey  are  also  favorable  ways 
of  taking  milk  where  alcohol  is  added  to  the  diet.  (See 
Recipe.) 

MILK  AS  A  FOOD  FOR  INFANTS 

To  use  cows'  milk  as  a  food  for  infants  it  is  necessary 
to  alter  or  modify  it  so  as  to  bring  its  chemical  composition 
to  resemble  more  closely  that  of  human  milk,  the  natural 
food  of  infants. 

Human  milk  contains  a  smaller  proportion  of  fats, 
proteins,  and  mineral  salts  than  cows'  milk,  and  a  larger 
proportion  of  sugar.  The  proportion  of  water  is  about  the 
same  in  either. 

Cows'  MILK.  HUMAN  MILK. 

Fats 4.0  per  cent.  3  to  4  per  cent. 

Sugar   (lactose) 4.5        "  6  to  7       " 

Protein 4.0        "  1  to  2       " 

Salts 0.7        "  0.2 

Water about  87.0  about  87.0 

The  protein  of  milk  is  composed  of  casein  and  lactalbu- 
min.  Casein,  as  we  have  seen  above,  is  difficult  of  diges- 
tion, while  lactalbumin  is  soluble  and  readily  absorbed. 

In  cows'  milk  the  proportion  of  casein  is  greatly  in  excess 
of  the  lactalbumin;  in  human  milk  there  are  nearly  three 
parts  of  lactalbumin  to  one  of  casein;  the  protein  of  human 
milk  is,  therefore,  more  easily  digested  than  that  of  cows' 
milk.  The  curds  formed  during  the  digestion  of  cows' 
milk  are  hard  and  dense;  those  of  human  milk  are  lighter, 
soft,  and  flocculent.  Cows'  milk  has  a  slightly  acid  reac- 
tion; that  of  human  milk  is  slightly  alkaline.  Human 
milk,  as  the  infant  receives  it,  is  free  from  any  external 
contamination,  either  from  bacteria  or  dirt,  and  is  at  the 


MILK  769 

natural  temperature  of  the  body;  cows'  milk,  on  the  other 
hand,  must  necessarily  be  handled,  can  only,  by  the  most 
scrupulous  care,  be  kept  from  contamination,  and  is  subject 
to  several  changes  of  temperature  before  it  is  given  to 
the  infant. 

Another  important  point  is  that  human  milk,  to  some 
extent,  changes  with  the  development  of  the  child,  in  order 
to  meet  the  demands  of  its  growth. 

From  the  above  it  will  be  seen  that  cows'  milk  cannot 
be  a  perfect  substitute  for  human  milk.  Very  frequently, 
however,  it  is  the  best  food  available.  In  these  circum- 
stances we  do  our  best  to  imitate  as  closely  as  possible  the 
human  milk  as  the  infants  receive  it.  The  process  of  alter- 
ation is  known  as  modification. 

To  modify  cows'  milk  we  first  ascertain  the  total  quan- 
tity in  ounces  required  for  a  given  number  of  feedings. 
We  then  take  as  a  basis  cream  of  a  known  percentage, 
say,  for  example,  16  per  cent. ;  this  will  supply  us  with  fats 
in  the  proportion  of  16  per  cent,  to  4  per  cent,  protein  and 
4.5  per  cent,  of  sugar. 

If  we  dilute  the  fats  with  water  down  to  the  required 
proportion  (3  to  4  per  cent.),  we  shall  also  reduce  the 
proteins  and  the  sugar,  and  we  already  have  too  small  a 
percentage  of  sugar  to  start  with.  We  must,  therefore, 
increase  these  ingredients. 

To  increase  the  protein  of  the  mixture,  we  add  skimmed 
milk,  which  is  free  of  fat,  but  contains  4  per  cent,  protein 
and  4.5  per  cent,  sugar;  the  sugar  we  increase  by  simply 
adding  a  sufficient  quantity  of  dry  sugar  of  milk. 

Finally,  when  we  have,  by  mixing  cream,  skimmed  milk, 
and  sugar,  obtained  the  full  amount  of  fat,  sugar,  and  pro- 
tein required  in  the  total  feedings,  we  take  a  sufficient 
quantity  of  water  to  make  up  the  necessary  bulk,  and 
divide  the  whole  amount  equally  into  the  number  of  feed- 
ings required. 

To  make  the  above  calculation  is  obviously  a  somewhat 
complicated  arithmetic  problem.  Several  formulas,  how- 
ever, have  been  devised  to  simplify  the  process,  by  means  of 
any  one  of  which  the  required  foods  may  be  quickly  pre- 
pared. 

49 


770  THE   PREPARATION   OF   FOOD 

One  in  common  use  in  hospital  work  is  by  Dr.  Baner. 
It  will  be  found  simple  to  use,  and  is  sufficiently  accurate 
for  practical  purposes. 

Dr.  Baner' s  Formula  for  the  Modification  of  Milk. 

Given :  The  quantity  desired  in  ounces. 
The  desired  percentage  of  fat. 
The  desired  percentage  of  sugar. 
The  desired  percentage  of  protein. 

To  find  in  ounces  cream,  milk,  water,  and  sugar  of  milk : 

Quantity     X      (Fats    —     Proteins) 
Percentage  of  cream    —    4. 


Milk 


/Quantity     X     Proteins\  „ 

v  4  / 


Water      =     Quantity    —     (Cream     +     Milk). 

(Sugar    —    Protein)     X     Quantity 
Sugar  ^Q- 

To  work  out  an  example,  let  us  take  a  formula  requiring 
a  percentage  of  fats  3,  sugar  6,  proteins  1 — about  the  aver- 
age composition  of  human  milk.  We  will  use  a  cream  with 
a  fat  percentage  of  16,  and  estimate  the  quantity  required 
at  20  ounces. 

To  find  the  cream  required: 

Q.  20  X  (F.  3  -  P.  1)  =  40  +  (percentage  of  cream  16  -  4)  = 
3 \  (cream  in  ounces). 

To  find  the  milk  required: 
Q.  20  X  P.  1  =  20  H-  4  =  5  -  Cream  3.33  =  If  (milk  in  ounces) 

To  find  the  water  required : 
Q.  20  -  (Cream  Z\  +  Milk  If)  =  15  (water  in  ounces). 

To  find  the  sugar  required: 
(S.  6  -  P.  1)  X  Q.  20  =  100  -s-  100  =  1  (sugar  in  ounces). 


MILK  771 

Thus,  to  modify  ordinary  cows'  milk  so  as  to  obtain  20 
ounces,  in  which  the  percentage  of  fats,  sugar,  and  proteins 
shall  be  3,  6,  1,  we  require: 

Cream  (16  per  cent.) 83  ounces. 

Milk  (skimmed) If       " 

Water 15 

20  ounces. 

Sugar  of  milk  1  ounce  (dissolved  in  the  whole  quantity) . 

In  hospital  work  the  percentage  of  fat  in  the  cream  is 
readily  ascertained  in  the  laboratory.  Where  this  is  not 
practical,  it  is  usual  to  use  the  tops  of  milk  bottles,  calcu- 
lating the  fat  in  the  following  manner: 

Upper  10  ounces,  10  per  cent. 

8  ounces,  12  per  cent. 

"         6  ounces,  20  per  cent. 

Cream  that  is  left  to  rise  and  not  separated  artificially  is 
known  as  gravity  cream. 

It  is  usually  easier  to  teach  the  pupils  to  carry  out  the 
calculation  in  decimal  fractions  rather  than  in  vulgar 
fractions.  In  estimating  the  quantity  in  ounces  (where 
the  metric  system  is  not  used  throughout)  the  ounce  may, 
to  facilitate  calculation,  be  taken  as  500  (480  minims), 
which  makes  each  y^  part  to  represent  50  minims  instead 
of  the  8  parts  of  60  minims  each. 

To  the  prepared  mixture  an  alkaline  is  frequently 
added  to  aid  in  the  digestion  of  the  protein,  since 
in  modifying  we  do  not  change  the  proportion  of  casein 
and  lactalbumin  in  the  protein,  and  the  casein  is  still 
in  excess.  To  help  in  the  digestion  of  the  casein  bicar- 
bonate of  soda  (^  grain  to  each  ounce)  is  frequently 
used,  or  lime-water,  from  y1^  to  ^  part.  If  lime- 
water  is  used,  a  correspondingly  smaller  proportion  of 
plain  water  will  be  required.  The  formula  to  find  the 
water  will  then  read: 

Water  =  Quantity  —  (Cream  +  Milk  +  Lime-water). 

Milk  is  one  of  the  best  media  for  the  cultivation  of  germs, 
and  it  becomes  a  question  in  what  way  we  can  best  re- 
produce the  sterile  quality  of  human  milk. 


772  THE   PREPARATION    OF   FOOD 

Sterilization. — At  one  time  it  was  considered  best  to 
sterilize  the  cows'  milk  by  subjecting  the  prepared  food 
to  a  temperature  of  212°  F.  for  thirty  minutes.  By  this 
process,  however,  much  of  the  nutritive  value  of  the  milk 
is  lost  in  the  scum,  which  collects  on  boiled  milk,  and  is 
very  difficult  to  reincorporate. 

Fat,  coagulated  albumin,  and  some  of  the  salts  of  milk, 
all  parts  of  high  nutritive  value,  are  contained  in  the  scum. 
Milk  also  appears  less  easily  digested  after  it  has  been 
boiled.  A  continued  diet  of  boiled  milk  quite  commonly 
causes  constipation  from  insufficiency  of  fat.  It  is  con- 
sidered that  the  exclusive  use  of  sterilized  milk  may  also 
be  a  cause  of  infantile  scurvy.  Where  sterilized  milk  is 
considered  necessary,  many  doctors  add  to  the  diet  the 
white  of  an  egg  (^  to  1  in  the  day)  and  a  small  quantity  of 
orange-juice  daily.  They  are  given  in  water  (separately) 
between  the  milk  feedings.  Orange-juice  is  not  usually 
ordered  until  after  the  sixth  month. 

At  the  present  time  pasteurization  is  preferred  to  com- 
plete sterilization.  In  pasteurizing  milk  the  prepared  food 
is  subjected  to  a  temperature  of  from  155°  to  167°  F.  for 
thirty  minutes.  (See  Recipe.)  At  this  temperature  patho- 
genic bacteria  (disease-producing  micro-organisms)  and 
also  the  non-pathogenic  micro-organisms  that  cause  the 
souring  of  milk  are  destroyed.  Spores  (p.  393)  are,  how- 
ever, not  destroyed  by  this  process,  and  if  allowed  time 
and  exposed  to  a  suitable  temperature,  may  develop. 
Pasteurization  is  not  considered  to  affect  materially  the 
nutritive  value  of  milk,  and  is,  for  practical  purposes, 
accepted  to-day  as  the  best  method  of  "insuring  uncon- 
taminated  milk. 

Keeping  Milk  Pure. — Where  the  milk  can  be  brought 
straight  from  the  cow  to  the  consumer,  under  strictly 
hygienic  conditions,  kept  during  the  transit  at  a  temperature 
not  above  45°  F.,  and  used  before  it  is  many  hours  old, 
most  doctors  consider  the  milk  is  best  digested  and  most 
nutritious  if  neither  pasteurized  nor  sterilized. 

It  then  becomes  doubly  necessary  to  preserve  the  milk 
from  contamination  or  from  changes  due  to  temperature 
while  storing  and  preparing  the  mixture.  The  whole 


MILK  773 

process  is  carried  out  under  strict  aseptic  precautions. 
The  bottles,  spoons,  etc.,  used  are  sterilized  previously 
by  boiling,  and  laid  out  conveniently  on  a  clean  sterile 
towel.  Rinsing  during  the  process  must  be  done  with 
sterile  water,  wiping  with  a  sterile  towel.  The  nurse's 
hands  should  be  scrubbed  as  for  an  operation,  and  kept 
clean  throughout.  As  a  further  precaution,  a  sterile  gown 
is  generally  worn  over  the  uniform  during  the  process. 

The  simple  implements  required  are  the  feeding-bottles, 
a  graduated  glass  for  measuring,  a  funnel,  a  spoon,  a 
pitcher  (containing  sterile  water),  and  sterile  non-absorb- 
ent cotton.  The  milk  and  cream  are  taken  direct  from 
the  bottle  in  which  they  are  delivered.  The  bottles 
should  be  kept  in  the  ice-box  until  required,  and  the  mix- 
tures replaced  in  the  ice-box  as  soon  as  they  are  prepared. 
The  feeding-bottles  each  contain  one  entire  feeding  only, 
a  sufficient  number  for  the  day's  feeding  being  prepared  at 
a  time;  they  are  corked  with  sterile  cotton  and  clearly 
marked  with  the  baby's  name  or  number.  At  the  hour  of 
feeding  the  bottle  is  placed  in  a  bowl  of  hot  water  until 
it  is  the  required  temperature,  and  a  clean  nipple  substituted 
for  the  cotton.  The  bottles  used  should  have  the  nipple 
directly  attached  to  the  bottle.  Rubber  tubing  is  im- 
possible to  keep  clean,  and  should  never  be  allowed. 

As  soon  as  the  bottle  is  finished,  it  should  be  rinsed  in 
cold  water,  washed  in  hot  suds,  rinsed,  and  set  aside  clean, 
to  be  sterilized  with  all  the  other  bottles  before  being  used 
again.  This  may  be  done  by  boiling  for  half  an  hour,  or 
by  placing  for  fifteen  minutes  in  the  autoclave. 

The  nipples  should  be  rinsed  inside  and  out  under  run- 
ning cold  water,  then  washed  in  hot  suds,  rinsed,  and  boiled 
for  five  minutes',  after  which  they  may  be  put  away  dry 
in  a  clean  sterile  towel  or  placed  in  a  jar  of  boric-acid 
solution  until  required.  Every  baby  should  keep  its  own 
nipple.  To  keep  the  nipples  from  floating  on  the  top  of  the 
antiseptic  solution,  they  may  be  loosely  tied  in  small 
squares  of  gauze,  to  a  bunch  of  which,  for  weight,  a  pair  of 
forceps  is  clipped,  otherwise  they  will  only  float. 

Whey,  buttermilk,  barley-water,  and  thin  gruels  may 
also  have  their  place  in  the  baby's  dietary  and  take  the 


774  THE   PREPARATION   OF  FOOD 

place  of  water  in  diluting  the  food.  (See  Recipe.)  When 
barley-water  or  gruel  is  used,  less  sugar  will  be  necessary, 
since  they  are  already  rich  in  carbohydrates.  Starchy 
foods  are  not  usually  ordered  before  the  eighth  month. 

In  giving  any  form  of  starch  to  a  baby,  it  is  necessary 
to  remember  that,  at  first,  there  is  no  ptyalin  in  the  saliva, 
and  that,  even  after  the  saliva  flows  freely,  the  percentage 
of  ptyalin  is  small.  Starches  must,  therefore,  be  dextrin- 
izecl,  either  by  prolonged  exposure  to  heat  or  by  the  addi- 
tion of  a  dextrinizing  agent.  (See  Recipe.)  After  the 
tenth  month  beef-juice  is  sometimes  used  for  feeble  in- 
fants. 

The  capacity  of  a  baby's  stomach  is  small,  and  the 
amount  of  food  given  at  a  time  must  be  regulated  accord- 
ingly. As  the  child  grows,  the  capacity  of  the  stomach  in- 
creases and  the  food  may  be  given  in  increased  quantities 
at  longer  intervals. 

CAPACITY  OF  THE  STOMACH 

At  birth 1    ounce. 

At  4  weeks 2|  ounces. 

At  8      "      3£ 

At  3  months 4 

At  5       "       5| 

At  9       "       7£ 

At  1  year 9 

The  feedings  are  usually  ordered  in  the  following 
quantities,  gradually  increased.  It  must  be  remembered 
that  the  weighing  scales  are  a  more  accurate  guide  to  the 
baby's  requirements  than  its  age. 

Day  (6-10)  Night  (10-6) 

First   week    (after 

first  two  days) .  .  6    drams  every  2    hours.         Every  2|  hours. 

Four  weeks 2    ounces  every  2  f  hours.         Twice  at  night. 

Three  months ....   3    ounces  every  3    hours.         Once  at  night. 

Five  months 4^  ounces  every  3    hours.         No  night  feeding. 

Nine  months 6    ounces  every  4    hours. 

One  year 8    ounces — 4  feedings. 

The  strength  of  the  food  is  gradually  increased  at  the 
same  time,  beginning,  during  the  first  week,  with  a  weak 
formula,  such  as  2,  5.50,  0.60,  and  increasing  as  the  diges- 


EGGS  775 

tion  will  bear  it,  until,  at  one  year,  the  child  can  take 
cows'  milk  undiluted.  If  the  child  is  tranquil,  gains  stead- 
ily in  weight,  and  has  well-digested  stools,  the  food  is 
agreeing  with  it  and  requires  no  alteration. 

If  the  weight  is  not  increasing  sufficiently,  usually  a 
stronger  formula  is  prescribed,  or  a  formula  with  a  larger 
proportion  of  sugar. 

After  the  ninth  month  starchy  foods  may  be  ordered. 
Proprietary  foods  should,  however,  be  looked  upon  with 
suspicion;  as  a  rule,  they  are  deficient  in  fats,  which  are  a 
prime  necessity  for  the  infant. 

Indigestion  may  be  shown  by  colic,  vomiting,  or  by  ab- 
normal stools,  all  of  which  are  important  points  to  observe. 

Regurgitation  and  vomiting  may  also  be  caused  by 
feeding  too  quickly  or  in  overlarge  quantities. 

Protein  indigestion  is  shown  by  colic,  vomiting,  diarrhea 
or  constipation,  and  the  presence  of  curds  in  the  stools. 

Carbohydrate  indigestion  is  shown  by  colic  and  thin, 
green,  acid  stools  that  "  scald  "  the  buttocks. 

Too  much  fat  causes  vomiting  toward  the  end  of  diges- 
tion, and  frequent  stools,  either  of  normal  appearance  or 
containing  fat.     Too  little  fat  is  the  commonest  cause  of 
constipation. 

EGGS 

Eggs  rank  next  to  milk  in  forming  a  nourishing,  easily 
digested  food  for  the  sick.  They  contain  all  the  food  ele- 
ments except  the  carbohydrates,  and  are  rich  in  mineral 
salts.  The  salts  are  present  in  "  organic  combination," 
which  make  them  readily  assimilated  by  the  body.  The 
white  of  egg  is  almost  pure  albumin  and  water,  and  is 
more  easily  digested  than  the  yolk,  which  is  a  highly 
complex  food-substance,  containing  fat,  protein,  and  a 
large  number  of  the  mineral  salts.  The  presence  of  sul- 
phur is  detected  easily  when  an  egg  begins  to  decompose. 
The  white  or  yolk  may  be  used  separately  or  together,  and 
either  raw  or  cooked,  measured  by  bulk.  Eggs  contain  a 
much  larger  amount  of  nourishment  than  milk.  Where  the 
digestion  is  feeble,  the  white  of  an  egg  dissolved  in  cold 
water  is  one  of  the  simplest  forms  of  nourishment,  and 
generally  well  borne.  (See  Recipes.) 


776  THE   PREPARATION   OF   FOOD 

The  first  quality  of  an  egg  is  that  it  should  be  fresh,  and 
especially  so  when  taken  raw. 

To  be  perfectly  fresh,  an  egg  should  not  be  more  than 
twenty-four  hours  old;  in  hospital  work,  however,  it  is 
commonly  impractical  to  obtain  eggs  the  day  they  are 
laid.  The  freshness  may  be  maintained  for  a  considerably 
longer  time  if  eggs  are  properly  cared  for.  The  egg-shell 
is  porous,  and  in  course  of  time  some  of  the  water  in  the 
egg  evaporates  through  the  shell,  the  place  of  which  is 
taken  by  air  from  outside.  We  see  the  effect  of  this  in  the 
little  air-space  at  the  top  of  a  boiled  egg.  If  the  egg  is 
new  laid,  the  space  is  very  small;  in  an  older  egg  it  is 
considerably  larger.  The  entrance  of  the  air,  which  may 
also  mean  the  entrance  of  bacteria,  is  the  cause  of  the 
decomposition.  Air  may  be  excluded  in  several  ways, 
but  it  must  be  remembered  that  the  material  used  will 
readily  impart  the  taste  to  the  egg.  To  keep  eggs  for 
immediate  use  as  fresh  as  possible  the  shells  should  be  clean, 
and  they  should  be  kept  at  a  low  temperature  in  the  larder 
or  ice-chest,  away  from  all  strong-smelling  foods,  such  as 
cooked  meat  or  vegetables. 

When  used,  each  egg  should  be  broken  separately  in  a 
cup,  as  one  turned  egg  will  cause  a  whole  dish  to  be  spoiled. 

The  albumin  of  eggs  coagulates  at  a  temperature  of 
134°  F.  If  exposed  to  high  temperature,  the  albumin  is 
tough  and  leathery,  less  palatable,  and  more  difficult  of 
digestion.  They  should,  therefore,  in  most  cases  be 
cooked  slowly  at  a  comparatively  low  temperature  (134° 
to  167°  F.).  The  yolk  will  cook  at  a  lower  temperature 
than  the  white. 

The  digestibility  of  eggs  is  also  increased  by  beating; 
this  ruptures  the  fine  capsule  which  incloses  the  particles 
of  albumin,  setting  the  albumin  free  to  be  acted  upon  by 
the  gastric  juice.  (See  Recipe.) 

GRUELS 

Gruels,  when  combined  with  milk,  are  rich  in  nutritive 
value,  and  form  usually  a  much-appreciated  variety  in  the 
monotony  of  a  restricted  diet.  Oatmeal,  wheat-meal,  bar- 


MEAT  BROTHS  AND  EXTRACTS         777 

ley-meal,  rice,  and  other  prepared  cereals  may  be  used. 
Oatmeal  gruel  has  a  laxative  effect,  and  is,  therefore,  pre- 
ferred where  active  elimination  is  desirable.  Barley 
gruel  and  rice  gruel  have  astringent  properties,  and  are 
preferred  in  cases  of  intestinal  irritation. 

In  cooking  cereals  it  must  be  borne  in  mind  that  long 
exposure  to  heat  is  necessary,  in  order  thoroughly  to  rup- 
ture the  cellulose  inclosing  the  starch-grains,  and  for  the 
purpose  of  partially  dextrinizing  the  starch.  Patent  invalid 
foods  are  frequently  used  instead  of  the  cereals  in  the 
preparation  of  gruels.  In  them  the  starch  is  usually 
already  dextrinized,  and  less  time  is,  therefore,  required 
for  the  cooking. 

We  have  seen  that  long  exposure  to  heat  destroys  some 
of  the  nutritive  value  of  milk;  milk  or  cream,  therefore,  is 
usually  added  at  the  end  of  cooking. 

Since  heat  also  converts  cane-sugar  into  glucose,  thus 
losing  much  of  the  sweet  taste,  if  sugar  is  desired,  it  should 
be  added  on  serving.  The  cereals  are,  however,  rich  in 
carbohydrates,  and  sugar  should  not  be  required. 

Salt  should  be  used  for  seasoning,  and  will  aid  in  diges- 
tion. 

Gruels  must  be  served  hot;  they  should  be  sufficiently 
thin  to  be  drawn  through  the  feeding-tube. 

MEAT  BROTHS  AND  EXTRACTS 

Beef-tea,  beef-juice,  chicken-tea,  and  mutton  broth 
are  frequent  additions  to  a  liquid  diet.  They  contain 
some  soluble  albumin,  mineral  salts,  a  little  fat  and  meat 
extractives,  and  a  large  proportion  of  water.  The  nutritive 
value  of  meat-teas  is  not  high,  but  the  meat  extractives  act 
as  stimulants  to  the  gastric  juice,  and  contain,  besides,  act- 
ive principles,  much  like  the  alkaloids  of  vegetable  drugs, 
which  have  a  stimulating  effect  on  the  nervous  system. 
Both  as  a  general  stimulant,  therefore,  and  as  a  stimulant 
to  the  appetite,  meat-teas  and  extracts  are  of  value.  They 
furnish,  besides,  an  acceptable  change  in  a  monotonous, 
restricted  diet.  The  nutritive  value  is  increased  by  the 
addition  of  toast,  croutons,  crackers,  or  well-boiled  rice. 


778  THE    PREPARATION    OF   FOOD 

It  is  on  account  of  the  stimulating  effect  of  the  meat  extrac- 
tives on  the  gastric  juice  that  a  hot  meat  soup  is  usually 
the  first  course  of  a  heavy  meal. 

In  preparing  beef-tea  or  beef-juice  the  lean  meat  from 
the  round  of  beef  is  used;  for  mutton  broth,  lean  meat  is 
cut  from  the  forequarter  of  lamb  or  tender  mutton,  the 
skin  and  fat  removed,  and  the  meat  cooked  with  the' bones; 
for  chicken  broth  the  whole  chicken  is  used,  with  the  skin 
and  fat  removed.  Where  the  digestion  is  delicate,  fat, 
especially  meat  fat,  will  often  cause  digestive  disorders, 
and  should,  therefore,  be  avoided.  In  order  to  extract 
all  the  nourishing  properties  of  the  meat-juices,  meat  to 
be  used  for  broths  or  teas  should  be  cut  up  in  small  pieces 
and  placed  in  cold  water,  which  is  then  slowly  brought  to 
the  temperature  necessary  for  cooking.  (See  Recipe.) 

WATER 

The  value  of  water  in  a  dietary  must  not  be  overlooked. 
As  a  solvent,  a  diluent,  and  as  an  aid  to  elimination  no 
food-stuffs  can  take  its  place,  and  although  it  is  consid- 
ered that  water  does  not  undergo  combustion,  but  passes 
out  from  the  body  still  as  water,  it  is  certain  it  has  an  influ- 
ence, probably  nearly  as  important  as  that  of  oxygen,  on 
metabolism. 

On  an  average,  from  four  to  six  pints  of  fluids  should  be 
taken  daily  in  the  form  of  drinking-water,  beverages,  soups, 
and  milk.  In  disease,  where  the  ordinary  processes  of 
nutrition  are  impaired,  a  certain  amount  of  water  should 
be  given  daily  over  and  above  that  represented  by  the  liquid 
diet,  remembering  that  water  in  a  pure  state  fulfils  its 
own  purpose  in  the  body  better  than  when  combined  with 
food-stuffs.  The  supply  should  not  be  left  to  chance,  and 
given  only  when  the  patient  complains  of  thirst,  but  be 
entered  as  part  of  the  diet  and  given  at  regular  hours. 

Conditions  where  water  should  be  pushed  are:  deficient 
elimination,  either  of  bowel  or  kidney,  toxic  conditions, 
fevers,  in  rheumatism,  gout,  and  other  conditions  associ- 
ated with  excess  of  uric  acid,  where  much  fluid  has  been  lost 
to  the  body,  as  after  severe  hemorrhages,  when  the  bleed- 
ing point  has  been  secured. 


BEVERAGES  779 

Water  is  restricted  where  dropsy  is  present,  in  effusions 
of  pleura  or  pericardium,  and  in  conditions  where  it  is 
desirable  to  promote  the  clotting  of  the  blood,  as  in  aortic 
aneurysm  or  hemorrhages,  where  the  local  lesion  cannot  be 
reached.  Fluid  is  also  restricted  in  the  condition  of  dilated 
stomach. 

Besides  its  general  purposes,  water  may  be  used  as  an 
aid  to  digestion. 

Hot  water  acts  as  a  stimulant  to  the  gastric  juice,  and  is  a 
useful  aid  to  deficient  elimination,  especially  in  bilious 
conditions. 

A  glass  of  hot  water  ten  minutes  before  meals  is  fre- 
quently prescribed  in  conditions  of  chronic  gastritis.  It 
washes  the  stomach  free  of  mucous  secretion,  and  promotes 
the  secretion  of  the  gastric  juice. 

Cold  water  has  the  important  effect  of  exciting  peris- 
talsis, and  for  this  reason  is  often  ordered  night  and  morn- 
ing in  the  treatment  of  constipation. 

Either  boiling  hot  water  or  iced  water  (or  ice)  in  small 
sips  is  useful  in  relieving  nausea  and  vomiting;  hot  water 
is  most  valuable  in  nausea  after  an  operation,  as  it  also 
allays  thirst,  which  ice  or  ice  water  frequently  appears  to 
increase. 

The  carbonated  waters — soda-water,  seltzer,  Vichy,  etc. 
— are  often  preferred  by  patients  to  ordinary  drinking- 
water,  and  are,  as  has  been  said,  especially  useful  in  the 
dilution  of  milk.  Soda-water  is  often  found  useful  in 
checking  vomiting.  Their  only  disadvantage  over  plain 
water  is  that  they  tend  to  produce  flatulence. 

Many  of  the  natural  mineral  waters  are  useful  for  special 
properties  in  the  aid  of  elimination,  and  are  not  used  as 
beverages;  such  are  Hunyadi  water,  Apenta,  and  others. 
Others,  such  as  lithia  water,  are  valuable  in  conditions 
associated  with  uric  acid,  and  may  be  taken  more  freely. 

BEVERAGES 

Where  it  is  difficult  to  induce  a  patient  to  take  a  sufficient 
amount  of  fluid,  he  may  often  be  induced  to  do  so  by  offer- 
ing it  in  the  form  of  a  beverage  with  an  agreeable  flavor 
or  appearance. 


780  THE   PREPARATION   OF   FOOD 

The  beverages  most  universally  used  and  constantly 
craved  by  patients  are  hot  tea  and  coffee.  Both  are  re- 
freshing, stimulating,  and  cheering,  and  to  some  extent 
both  diuretic  and  diaphoretic.  Taken  at  night,  they 
cause  wakefulness,  and  the  abuse  of  either  induces  a  con- 
dition of  nervousness  not  unlike  the  abuse  of  alcohol  and 
tobacco. 

Unfortunately,  both  tea  and  coffee  are  apt  to  produce 
disorders  of  digestion,  and  are.  therefore,  not  usually  in- 
cluded in  the  diet  of  very  sick  persons  or  invalids  of 
weak  digestion. 

Tea. — The  indigestibility  of  tea  is  due  to  the  tannin. 
Tea  may  be  prepared  with  a  minimum  amount  of  tannin  in 
the  following  manner: 

Place  two  teaspoons  of  tea  in  a  small  pot,  previously 
well  heated;  add  just  sufficient  boiling  water  to  cover  the 
leaves,  cover,  and  let  stand  for  three  minutes;  pour  off 
the  tea  into  a  heated  cup,  and  add  sufficient  boiling  water 
to  dilute;  sugar  and  cream  or  lemon  may  be  added. 

By  this  method  the  thein  (the  active  principle  of  tea), 
which  is  readily  dissolved,  is  extracted  and  forms  a  satu- 
rated solution  which  will  not  pick  up  the  more  slowly  dis- 
solved tannin.  In  any  case  the  longer  the  water  stands  on 
the  leaves,  the  more  tannin  will  be  extracted.  Freshly 
made  tea  that  does  not  stand  more  than  three  minutes 
before  being  poured  off  the  leaves  should  be  the  rule  in  the 
sick-room. 

The  tannin  in  tea  checks  digestion;  strong  tea  is, 
therefore,  an  unsuitable  beverage  to  take  with  a  heavy 
meal,  and  its  use  in  this  respect  is  a  common  cause  of 
dyspepsia. 

Coffee,  if  taken  in  excess,  is  apt  to  produce  nervousness, 
insomnia,  and  biliousness.  It  contains  an  oil  which  is  the 
cause  of  its  bilious  effect,  but  also  produces  a  slightly 
laxative  action  on  susceptible  people.  Black  coffee  is 
a  good  general  stimulant,  and  useful  in  cases  of  lowered 
vitality;  it  is  frequently  given  by  enema  in  conditions  of 
shock  and  collapse.  A  small  quantity  of  black  coffee  at  the 
end  of  a  meal  is  considered  to  aid  digestion. 

The  best  coffee  is  made  by  the  drip  method,  from  freshly 


BEVERAGES  781 

ground  beans.  The  flavor  is  spoiled  if  it  is  allowed  to  boil. 
Coffee  for  the  sick-room  should  be  freshly  made. 

Coffee  and  tea  have  no  food  value,  except  in  so  far  as 
mirk,  cream,  or  sugar  may  be  served  with  them. 

Chocolate  and  cocoa  are  rather  foods  than  beverages, 
since  they  contain  carbohydrates,  fats,  and  proteins, 
besides  a  stimulating  principle,  theobromin,  and  represent 
considerable  nutritive  value. 

Beverages  made  from  fresh  fruits  and  fruit  syrups  are 
refreshing  and  easily  made.  The  sugar  and  the  vegetable 
acids  they  contain  give  a  small  proportion  of  food  value. 

Starchy  beverages  are  frequently  ordered  in  cases  of 
intestinal  irritation;  the  most  important  are  barley-water 
and  rice-water.  They  have  a  slightly  astringent  effect  on 
the  mucous  membrane  of  the  intestines. 

The  value  of  alcoholic  drinks  in  illness  is  largely  a  matter 
of  opinion,  and  is  governed  by  many  considerations:  the 
previous  habits  of  the  patient,  the  necessity  for  stimulation, 
the  state  of  the  digestion,  and  so  forth.  They  belong  more 
to  the  physician,  rather  than  to  the  dietitian,  and  in  illness 
are  practically  medicines.  Hot  alcoholic  drinks,  such  as 
whisky  toddy,  have  a  quick  diaphoretic  effect,  and  are 
useful  in  the  breaking  up  of  a  cold.  They  are  also  valuable 
where  much  of  the  body  heat  has  been  lost  from  exposure  or 
fatigue. 


CHAPTER  XXIII 
DIETS  AND  DIETING 

General  Division  of  Diets — Selection  of  Diet — Liquids — Eggs, 
Meats,  Fish,  Vegetables,  Fats,  Carbohydrates — Some  General 
Points — Diet  in  Special  Diseases:  Fevers,  Typhoid  Fever,  Acute 
Gastric  and  Intestinal  Disorders,  Gastric  Ulcer,  Diarrhea,  Infantile 
Diarrhea,  Chronic  Dyspepsia,  Dilated  Stomach,  Obstruction  of  Bile- 
ducts,  Chronic  Constipation,  Nephritis,  Dropsy,  Salt-free  Diet,  Dia- 
betes, Phthisis,  Scurvy,  Rickets,  Anemia. 

GENERAL  DIVISION  OF  DIETS 

IN  hospital  work  the  patient's  food  is  ordered  under  the 
heading  of  certain  standard  diets,  except  in  cases  requiring 
special  dieting.  The  usual  divisions  are  milk  diet,  liquid 
diet,  semisolid  diet,  house  diet,  house  diet  with  care,  and 
extra  diet.  The  quantities  are  prescribed,  and  the  nurse's 
chief  responsibility  is  to  see  the  patient  gets  the  right 
amount,  properly  served.  In  private  work  a  nurse  may 
find  herself  left  much  more  to  her  own  resources,  both  as 
to  the  selection  of  food  and  the  quantities  in  which  they 
may  be  given.  She  may  have  no  more  precise  orders  than 
"  a  light,  nourishing  diet,"  or  "  keep  him  on  liquids";  it 
is  then  very  essential  that  she  should  know  the  average 
quantities  necessary,  and  the  forms  in  which  foods  are 
most  easily  digested. 

Liquid  Diet. — This  includes  milk,  buttermilk,  whey,  etc., 
egg-albumen,  broths,  bouillons,  barley  and  rice  water,  thin 
gruels,  and  beverages.  From  four  to  six  pints  are  the  aver- 
age allowed.  Where  milk  is  taken,  generally  two-thirds 
of  the  diet  should  be  milk;  of  the  remaining  third,  one-half 
should  contain  nourishment,  as  in  broths,  egg-albumen, 
and  gruels,  and  one-half  be  pure  water  or  beverages. 
Where  milk  is  the  only  diet,  the  form  in  which  the  milk  is 
given  should  be  varied.  Few  patients  can  take  more  than 
three  or  four  pints  of  milk  in  the  day.  Extra  liquid  to 
relieve  thirst  should  be  given  as  water  or  beverages,  with- 

782 


GENERAL   DIVISION   OF   DIETS  783 

out  food-stuffs.  The  whole  quantity  should  be  divided 
into  feedings,  and  given  at  regular  intervals.  In  a  sick 
diet  not  more  than  5  ounces  of  plain  milk  should  be 
given  at  a  time;  of  diluted  milk,  broths,  etc.,  not  more  than 
10  ounces;  thin  gruels,  from  5  to  8  ounces;  beef-juice, 
|  to  1  ounce.  Whole  milk  may  be  diluted  with  carbonated 
waters,  lime-water,  etc.,  as  above.  The  most  digestible 
forms  of  milk  are  whey,  buttermilk,  and  fermented  milks 
(koumiss,  etc.).  Where  cream  is  well  borne,  it  is  of  great 
use  on  account  of  its  high  caloric  value. 

Broths  and  bouillons  made  from  beef  are  more  irritating 
to  the  intestinal  tract,  on  account  of  their  extractives,  than 
those  made  from  mutton  or  chicken.  They  should  be  made 
from  lean,  tender  meat,  with  all  fat  carefully  removed. 
(See  Recipe.)  It  must  be  remembered  that  broths,  bouil- 
lons, and  beef-extract  preparations  are  valuable  chiefly 
as  stimulants  to  the  digestion,  and  as  affording  variety  to 
a  monotonous  diet,  and  contain  little  of  nutritive  value. 
Egg-albumen  and  gruels  are  foods  and  have  distinct  caloric 
value.  As  meat  extractives  are  to  some  extent  irritating 
to  the  alimentary  tract,  they  are  often  useful  in  overcom- 
ing constipation,  and  are  contraindicated,  as  a  rule,  in  con- 
ditions associated  with  diarrhea. 

In  any  case  of  gastric  or  intestinal  disorder  liquids  should 
be  given  cool :  either  very  hot  or  very  cold  drinks  tend  to 
aggravate  the  trouble. 

Even  a  fluid  diet  may  cause  indigestion,  the  symptoms 
of  which  may  include  nausea,  vomiting,  flatulence,  dis- 
tention,  coated  tongue,  and  diarrhea  or  constipation,  the 
latter  symptoms  especially  from  an  exclusive  milk  diet. 
Most  commonly  it  is  the  proteins  that  cause  digestive 
troubles,  especially  the  casein  .of  milk.  The  milk  may  be 
altered  or  diluted,  as  already  described;  lime-water  or 
bicarbonate  of  soda  may  be  added,  with  the  object  of 
making  the  curds  less  heavy,  or  the  protein  may  be  pre- 
digested  by  a  peptonizing  agent.  Another  method  of  help- 
ing the  enfeebled  digestion  is  by  giving  regularly,  in  small 
doses,  dilute  hydrochloric  acid  (3  to  5  minims),  or  some 
preparation  of  pepsin,  thus  supplying  the  gastric  juice  arti- 
ficially with  what,  in  a  normal  condition,  is  called  forth  by 


784  DIETS   AND   DIETING 

a  mixed  diet.  The  use  of  a  small  amount  of  table-salt  in  the 
milk  is  also  a  valuable  aid  to  digestion. 

The  return  from  a  liquid  to  a  solid  diet  must  be  gradual. 
A  long  continuance  of  fluid  or  bland  food-stuffs  renders  the 
stomach  unaccustomed  to  digest  solids,  and  a  short  time 
must  elapse  before  the  gastric  juice  becomes  reestablished 
in  its  normal  condition.  The  diet  should  be  increased  first 
by  easily  digested  foods,  such  as  gruels,  cocoa,  soft-boiled 
eggs,  junket,  farinaceous  puddings,  baked  potatoes, 
oysters,  and  so  forth.  The  stools  should  be  examined  to 
insure  that  the  food  is  being  well  digested. 

Eggs. — Eggs  are  most  digestible  if  taken  raw,  either 
plain  or  as  eggnog,  or  soft  boiled.  Taken  with  an  or- 
dinary liquid  diet,  two  to  four  are  usually  given  in  the 
twenty-four  hours,  except  in  cases  of  forced  feeding. 
Fried  eggs,  or  eggs  cooked  with  butter,  must  be  avoided 
in  all  disorders  of  the  digestion. 

Meats. — The  most  digestible  meats  are  those  containing 
least  fat  or  muscle-fiber;  young  meats  are  tenderer  than 
meat  from  older  animals,  and  white  meat  than  dark  meat. 
Red  meats,  especially  beef,  are  irritating  on  account  of 
the  extractives,  and  are,  therefore,  not  generally  given 
where  the  digestion  is  feeble.  Meat  may  be  made  more 
digestible  by  being  finely  divided,  as  in  mincing  or  scraping. 
The  most  digestible  meats  are  sweetbreads,  white  meat  of 
chicken,  pigeon,  and  tripe.  Where  red  meat  is  ordered, 
broiled  lamb-chops  or  tenderloin  steak  are  best  to  begin 
with. 

Meat  is  usually  tenderest  and  most  palatable  if  lightly 
broiled  or  roasted;  boiling  is  permissible  with  chicken  or 
mutton  if  it  is  impossible  to  get  young  meat.  Fried  meat 
should  never  be  given  in  the  sick-room.  Gravies  and  seas- 
oned sauces  should  also  be  avoided.  Commonly  speaking, 
meat  is  best  given  at  the  midday  meal;  if  preferred  at  the 
evening  meal,  at  least  three  hours  should  intervene  before 
bedtime. 

Fish. — The  fish  to  be  avoided  are  those  containing 
much  fat — salmon,  mackerel,  herring,  bluefish,  and  shad. 
White  fish,  such  as  whiting,  flounder,  carp,  halibut, 
white-bait,  and  others,  are  suitable.  They  are  more  digest- 


GENERAL   DIVISION   OF   DIETS  785 

ible  boiled,  broiled,  or  scalloped.  If  fried,  all  grease  must 
be  carefully  removed.  Oysters  and  clams  may  be  eaten 
raw  or  stewed;  in  this  way  they  are  more  digestible  than 
if  panned  or  fried. 

Vegetables. — The  most  digestible  vegetables  are  those 
with  the  least  amount  of  cellulose.  Cabbage  contains  a 
large  amount,  and  elaborates  much  gas  during  its  digestion. 
Peas  and  beans  tax  the  digestion  considerably,  both  from 
the  amount  of  cellulose  they  contain  and  also  from  the 
large  percentage  of  protein.  If  allowed,  the  vegetables 
must  be  very  young  and  cooked  until  soft.  Potatoes 
should  be  well  cooked,  in  order  partially  to  dextrinize 
the  starch;  they  are  most  digestible  baked  or  thoroughly 
mashed.  Coarse  vegetables,  cabbage,  turnips,  carrots, 
onions,  and  radishes,  should  be  avoided  in  the  sick-room. 
The  most  digestible  green  vegetables  are  asparagus-tops 
and  the  flower  of  cauliflower.  They  should  be  well  boiled, 
and  eaten  without  seasoning,  except  salt.  Fruits  are 
usually  acceptable,  and,  although  not  nutritious,  they  are 
refreshing  and  please  the  appetite.  On  account  of  the 
acids  they  contain,  they  should  not,  where  the  digestion  is 
delicate,  be  taken  with  milk.  Where  the  digestion  is 
weak,  the  juice  only  should  be  given.  Grapes,  orange- 
juice,  and  lemon-juice  may  usually  be  given  freely. 
Peaches,  pears,  grape-fruit,  and  berries  must  be  given  with 
more  discretion.  All  fruits  must  be  thoroughly  ripe  and 
perfectly  fresh. 

Carbohydrates.— In  a  liquid  diet  carbohydrates  are 
given  in  the  form  of  barley-water,  rice-water,  and  thin 
gruels.  Where  more  solid  food  is  taken,  bread,  rusks, 
toast,  well-cooked  cereals,  and  farinaceous  puddings  are 
the  usual  means.  All  starchy  food  must  be  cooked  slowly 
and  thoroughly,  in  order  partially  to  dextrinize  the  starch 
and  so  spare  digestion. 

Hot  bread,  hot  buttered  toast  or  cakes,  and  scones, 
etc.,  made  with  butter  or  served  hot  with  butter,  are  diffi- 
cult to  digest.  The  melted  butter  surrounds  the  starch 
grains,  and  prevents  any  action  of  the  digestive  ferments, 
until  the  fats  have  first  been  acted  upon. 

Fat. — Where  the  diet  is  liquid,  fat  is  given,  either  in 

50 


786  DIETS  AND   DIETING 

whole  milk  or  cream,  and  is  an  important  part  of  all  diets, 
except  in  certain  cases  of  intestinal  indigestion.  To  con- 
valescents an  increase  of  fat  is  best  given  as  butter,  with 
toast,  bread,  etc.,  and  in  the  fat  of  cooked  meats.  Chocolate 
may  also  be  ordered  for  the  fat  it  contains.  Speaking 
generally,  fat  should  not  be  used  in  the  cooking  of  meals 
in  the  sick-room,  either  in  the  form  of  butter,  dripping, 
or  oil. 

SOME  GENERAL  POINTS 

A  few  working  rules  a  nurse  may  bear  in  mind  concern- 
ing the  diet  of  her  patients: 

See  that  the  food  is  ready  punctually,  and  served  at 
regular  intervals:  the  intervals  should  be  sufficiently  long 
for  the  stomach  to  have  a  period  of  rest,  and  not  long 
enough  for  the  patient  to  become  in  any  degree  exhausted 
for  want  of  food. 

Insist  that  all  solid  food  be  properly  chewed  and  eaten 
slowly. 

Remember  that  food  is  better  digested  if  it  is  liked; 
tempt  the  patient's  appetite  with  variety,  small  surprises, 
and  dainty  service.  Worry,  temper,  and  overexcitement 
affect  the  digestive  processes:  see  that  the  atmosphere  of 
the  sick-room  is  pleasant  during  mealtime. 

Allow  sufficient  time  for  digestion  between  the  last  meal 
and  bedtime,  since  the  digestive  processes  are  sluggish 
during  sleep. 

Serve  hot  foods  very  hot  and  cold  foods  really  cold; 
avoid  either  extreme  of  temperature,  especially  hot  or 
ice-cold  fluids,  in  all  cases  of  gastric  disorder,  especially 
if  associated  with  diarrhea  or  ulcerated  conditions. 

Omit  altogether,  in  the  diet  of  the  sick,  spices,  season- 
ings, rich  gravies  and  sauces,  and  fried  foods;  never  serve 
farinaceous  foods  with  melted  butter,  such  as  hot  cakes, 
hot  buttered  toast,  etc. 

In  giving  liquids  to  patients  in  bed,  use  either  the  feeding 
cup  or,  as  is  generally  preferred,  a  glass  tube  bent  to  a 
convenient  angle.  If  neither  is  procurable,  pour  a  small 
quantity  at  a  time  into  a  tumbler,  and  raise  the  head 
slightly  by  passing  the  arm  under  the  pillow. 


DIET   IN   SPECIAL   DISEASES  787 

If  a  patient  is  unconscious,  he  may  be  given  liquid  food 
with  a  spoon;  the  mouth  is  opened  by  pressing  the  chin 
downward  or  by  pressing  the  cheek  on  either  side  against 
the  back  teeth,  using  the  finger  and  thumb  of  the  left  hand. 
The  food  is  passed  to  the  back  of  the  mouth,  pressing  the 
tongue  gently  down  with  the  spoon,  and  will  generally  be 
swallowed. 

Where  the  patient  cannot  be  induced  to  swallow,  he  may 
be  fed  through  the  nose  with  a  medicine-dropper,  passing 
the  dropper  into  the  nostril  and  directly  backward.  The 
liquid  will  trickle  directly  into  the  pharynx,  and  usually 
be  swallowed.  For  patients  in  this  condition  gavage  is 
generally  preferred. 

A  baby  should  be  taken  on  the  arm,  or  turned  on  its 
side  in  its  cot,  and  given  its  bottle  slowly,  with  a  little 
pause  from  time  to  time.  Many  babies  learn  to  bolt  their 
food  by  being  left  to  take  their  bottle  alone;  others,  that 
are  slow  feeders,  leave  their  bottles  until  they  are  cold, 
or  neglect  to  take  the  whole  amount.  A  young  baby 
should  never  be  left  to  take  its  bottle  alone. 

DIET  IN  SPECIAL  DISEASES 

At  the  present  day  the  question  of  diet  in  the  treatment 
of  disease,  and  especially  of  the  more  chronic  varieties, 
has  assumed  an  immense  importance.  In  some  respects 
scientific  dieting  is  still  in  the  experimental  stage,  and 
nurses  must  be  prepared  to  meet  with  contradictory  opin- 
ions and  varying  methods. 

In  the  large  majority  of  diseases  we  meet  the  need  for 
some  alteration  in  the  normal  diet.  The  diet  may  be 
altered  to  suit  the  requirement  of  a  special  organ,  as  when 
we  omit  the  proteins  where  the  kidneys  are  diseased,  or 
the  carbohydrates  in  cases  of  diabetes.  All  toxic  condi- 
tions are  accompanied  by  digestive  disturbances;  food 
must,  therefore,  be  given  in  these  circumstances  in  its 
simplest  and  most  digestive  forms,  and,  at  the  same  time, 
it  must  frequently  be  contrived  so  as  to  increase  its 
caloric  value.  The  most  common  condition  in  which 
strict  dieting  is  a  principal  part  of  the  treatment  is  in 


788  DIETS   AND   DIETING 

disorders  and  diseases  of  one  or  other  part  of  the  digestive 
tract. 

A  diet  is  succeeding  when  it  is  bringing  about  the  effect 
for  which  it  is  prescribed.  If  the  kidneys  are  improving, 
there  will  be  less  albuminuria  and  fewer  casts  in  the  urine; 
under  a  strict  diabetic  diet  only  a  minimum  quantity  of 
sugar  will  be  excreted  in  the  urine,  and  so  forth;  for  special 
conditions  the  nurse  must  watch  special  points  for  the 
results.  For  general  purposes,  a  diet  is  agreeing  with  a 
patient  when  he  increases  in  weight,  or,  at  least,  in  an 
adult,  does  not  lose  weight,  is  placid  in  mind,  digests  his 
food,  shows  a  reasonable  appetite,  and  the  excreta  are 
normal.  The  consistence  and  appearance  of  the  bowel 
movements  are  the  most  important  indications  of  the 
satisfactory  digestion  of  a  diet;  in  cases  of  disordered  di- 
gestion, from  whatever  cause,  and  in  any  case  of  special 
dieting,  their  inspection  should  never  be  left  to  inexperi- 
enced persons. 

It  is  only  possible,  in  a  book  of  this  size,  to  take,  as  ex- 
amples of  special  dieting,  the  diseases  most  frequently 
met  with,  in  which  strict  dieting  in  a  prominent  part  of 
the  treatment. 

Fevers. — The  condition  we  know  as  fever  most  commonly 
is  the  result  of  the  presence  of  toxins  in  the  body  (Chap. 
XI) ;  it  is  always  associated  with  certain  phenomena — raised 
temperature,  prostration,  waste  of  the  tissues,  loss  of  appe- 
tite, and  derangement  of  the  natural  processes  of  digestion 
and  metabolism.  The  diet  to  combat  these  conditions  must 
contain  all  the  food  elements,  must  be  sufficient  to  combat 
to  some  extent,  the  tissue  waste,  must  be  nourishing,  easily 
digested  and  assimilated,  and  should  include  a  large  supply 
of  water.  Taken  in  sufficient  quantity,  water  acts  as  a 
diluent  to  the  toxins,  and  also  furthers  their  elimination 
by  the  natural  excreta.  It  is  given  freely  in  all  fever  cases 
unless  contraindicated  by  other  conditions,  such  as  gen- 
eral dropsy  or  effusion  of  one  of  the  serous  cavities. 

A  liquid  diet  is  the  most  suitable  for  this  condition,  such 
as  has  been  described.  The  diet  may  be  exclusively  of 
milk,  or  varied  in  the  ways  suggested.  If  diarrhea  is  a 
symptom,  the  milk  may  be  ordered  boiled,  diluted  with 


DIET   IN  SPECIAL  DISEASES  789 

lime-water,  or  given  with  equal  parts  of  barley-water. 
In  certain  conditions,  to  be  described  presently,  milk  may 
be  withheld  altogether. 

When  constipation  is  present,  milk  may  be  given  with 
a  larger  proportion  of  cream,  or  diluted  with  the  natural 
waters  or  with  thin  oatmeal  gruel;  broths  and  bouillons 
may  also  aid  in  overcoming  this  condition  by  their  stimu- 
lating effect  on  the  alimentary  canal. 

In  the  mild  fevers  that  accompany,  for  example,  the 
common  cold,  bronchial  catarrh,  etc.,  hot  drinks  and  hot 
gruels  may  be  added,  with  the  object  of  encouraging 
sweating. 

Typhoid  Fever. — In  typhoid  fever  we  have  some  special 
conditions  that  must  be  taken  into  consideration  in  the 
dieting.  We  have  an  infection  that  develops  slowly,  pro- 
duces a  profound  toxemia  lasting  over  a  considerable 
length  of  time,  and  is  characterized  by  a  rapid  waste  of 
the  tissues  and  marked  prostration.  Further,  typhoid 
fever  is  associated  with  ulceration  of  certain  glands  in  the 
walls  of  the  small  intestines;  in  severe  cases  these  ulcers 
burrow  deeply  into  the  wall  of  the  intestine,  and  irritation 
of  these  parts  from  decomposition  of  food-particles  or 
distention  of  the  walls  from  gases  so  elaborated  may  result 
in  rupture  of  a  blood-vessel  so  exposed  or  perforation, 
where  the  walls  of  the  vessel  have  been  worn  thin  by  the 
burrowing  ulcer. 

In  choosing  the  diet,  we  must  have  one  that  will  counter- 
act the  tissue  waste,  put  the  body  in  the  best  condition 
to  resist  the  prolonged  attack  of  the  invading  infection, 
and,  at  the  same  time,  will  not  overtax  the  deranged 
digestion  or  leave  an  indigestible  residue  to  irritate  the 
intestinal  ulcers. 

Formerly,  the  classic  diet  for  all  typhoid  cases  was  a  strict 
liquid  diet,  composed  chiefly  of  milk,  diluted  with  Vichy 
or  lime-water,  to  which  strained  chicken  and  mutton 
broth  and  beef-tea  were  added,  provided  there  was  no 
diarrhea  nor  very  acute  toxic  symptoms  which  would 
suggest  extensive  ulceration.  The  diet  suited  the  gastric 
condition,  but  did  little  to  combat  the  tissue  waste  or  the 
prostration,  which  in  themselves  may  be  a  menace  to  life. 


790  DIETS   AND   DIETING 

At  the  present  day  our  ideas  on  diet  have  been  much 
modified  by  the  more  definite  knowledge  available  on  the 
comparative  value  of  the  different  food-stuffs  as  energy- 
producers,  as  we  saw  in  a  previous  chapter.  We  saw 
(Chap.  XXI)  that  the  diet  of  a  man  of  average  weight  in 
normal  conditions  should  yield,  roughly,  between  35  and 
40  calories  for  each  kilogram  of  his  body  weight,  which 
energy  he  uses  up  in  functional  and  motor  activity  and  in 
the  repair  of  the  tissues. 

In  typhoid  fever  we  have,  although  we  keep  the  body 
at  rest,  a  waste  of  tissue  out  of  all  proportion  to  what  could 
be  caused  by  any  physical  activity,  and  an  abnormal  heat- 
production  due  to  the  febrile  condition.  We  have,  there- 
fore, a  condition  in  which  an  increased  amount  of  energy 
is  used  up,  and  should  be  counterbalanced  by  an  increased 
number  of  calories  in  the  diet;  at  the  same  time  we  have 
an  enfeebled  digestion  and  an  irritable  alimentary  tract. 
It  is  estimated  that  the  average  typhoid-fever  patient  re- 
quires an  increase  of  25  per  cent,  calories  in  his  diet,  in 
order  to  combat  the  tissue  waste  and  the  loss  through  the 
abnormal  heat-production,  and  to  increase  his  resistance  to 
the  infection.  It  is  a  condition,  then,  in  which  a  high  caloric 
diet  is  of  special  value;  at  the  same  time  the  diet  must  be 
chosen  to  throw  a  minimum  of  work  on  the  enfeebled 
digestion. 

In  whatever  school  the  nurse  works  at  the  present  day 
she  will  probably  find  some  scheme  or  schedule  for  the  high 
caloric  diet  of  typhoid-fever  patients,  and  the  accurate 
administration  of  such  is  almost  the  most  important  part 
of  her  share  in  the  care  of  the  patient. 

The  patient  is  weighed  regularly,  frequently  daily, 
and  every  article  of  his  diet  must  also  be  weighed  and 
measured.  As  many  fever  patients  display  little  appetite, 
much  tact,  discretion,  and  perseverance  may  be  called  for 
in  inducing  the  patient  to  take  the  necessary  amount. 

The  number  of  calories  prescribed  depends  on  the  weight 
of  the  patient;  the  average  high  caloric  diet  allows  from 
60  to  80  calories  for  each  kilogram  of  the  patient's  weight, 
and  in  special  cases  an  even  higher  number  is  given.  If 
the  diet  is  successful  after  the  first  week,  the  patient  gains 


DIET    IN    SPECIAL   DISEASES  791 

steadily  in  weight — often  as  much  as  three  pounds  and 
over  in  the  week. 

In  all  the  schedules  cream,  eggs,  milk  in  some  form,  milk- 
sugar,  and,  usually,  butter  are  the  staple  articles  of  diet. 
Eggs  are  most  digestible  if  taken  soft  boiled;  milk-sugar  is 
used  instead  of  cane-sugar,  as,  being  only  half  as  sweet,  a 
much  larger  quantity  can  be  given  in  the  diet.  The  sweet 
taste  is  further  lessened  by  cooking.  If  the  sugar  is  to  be 
added  to  uncooked  foods,  such  as  fruit-drinks,  it  may  first 
be  boiled  in  water  for  two  minutes.  The  quantity  of  each 
of  these  foods  necessary  to  furnish  100  calories  is  as  follows : 

White  of  eggs 5 

Yolks 2 

Cream  (20  per  cent.) 45  c.c. 

Milk 150  c.c. 

Whey 180  c.c. 

Sugar 45  gm. 

Butter 15  gm. 

To  the  above  are  added  well-cooked  cereals, — oatmeal, 
hominy,  or  wheatena, — corn-starch  and  tapioca  puddings, 
custards,  ice-cream,  wine  and  fruit  jellies,  toast,  stale 
bread  or  simple  crackers,  with  which  the  patient  is  induced 
to  eat  as  much  butter  as  possible.  Milk-sugar  is  used  in 
the  cooking,  as  well  as  taken  with  the  milk,  cream,  and 
other  drinks.  It  is  given  in  small  quantities  at  first,  not 
more  than  |  ounce,  and  gradually  increased  until  from 
4  to  6  ounces  can  be  taken  in  half  a  pint  of  fluid.  Cream  is 
given  pure  or  diluted  with  milk,  etc.,  as  well  as  served 
with  various  foods.  Coffee  or  tea  with  cream  and  milk- 
sugar  or  cocoa  is  served  with  the  morning  meal.  Some 
doctors  add  to  this  diet  scraped  beef,  finely  minced  chicken, 
and  boiled  whitefish  or  beef-juice;  others  omit  meat  or 
meat-juice  entirely  during  the  acute  stage. 

When  the  digestion  is  abnormally  sensitive,  the  diet 
may  be  exclusively  of  cream,  milk,  and  milk-sugar;  usually, 
however,  the  more  mixed  diet  is  well  borne.  If  the  patient 
shows  symptoms  of  indigestion,  such  as  vomiting,  diarrhea, 
or  the  presence  of  curds  in  the  stools,  he  may  be  given 
peptonized  milk  for  a  short  period,  until  the  digestion  is 
reestablished,  when  the  diet  is  gradually  resumed. 


792  DIETS  AND   DIETING 

Patients  are  usually  given  their  three  principal  meals,  as 
breakfast,  dinner,  and  supper,  with  additional  feedings 
either  every  two  or  three  hours,  according  to  the  amount 
of  nourishment  necessary  and  the  quantity  the  patient  can 
take  at  a  time.  At  the  beginning  the  quantity  taken  may 
be  small,  but  should  be  increased  perseveringly.  Only 
liquid  food  is  given  at  night.  Water  should  also  be  taken, 
and  may  be  given  with  fruit-juice,  sweetened  with  milk- 
sugar,  if  there  is  difficulty  in  getting  in  the  full  amount  of 
calories. 

A  diet  scheme  in  one  of  the  leading  hospitals  gives,  in  the 
daily  diet,  an  average  of  1  to  2  pints  of  cream,  2  to  3  pints 
of  milk,  \  to  1  \  pounds  of  milk-sugar,  from  3  to  6  eggs,  and 
as  much  butter  as  the  patient  will  eat  with  stale  bread  or 
toast. 

When  the  temperature  falls,  solids  are  added  to  the  diet, 
beginning  with  baked  potatoes,  sweetbreads,  finely  minced 
chicken,  and  broiled  squab,  and,  finally,  broiled  chop  and 
tender  steak  as  the  digestion  is  accustomed  to  the  increased 
diet. 

Throughout  the  whole  course  of  the  illness  the  stools 
should  be  inspected  by  an  experienced  person,  to  insure 
that  the  diet  is  being  well  digested. 

Gastric  and  Intestinal  Disorders. — No  special  rules  or 
diet-lists  can  be  laid  down  for  the  treatment  of  gastric 
or  intestinal  disorders  which  will  cover  all  cases.  It  may 
be  assumed  that  in  no  class  of  disease  is  it  more  necessary 
that  the  patient  should  seek  the  advice  of  a  specialist 
on  this  point.  Not  only  may  the  individual  case  vary 
greatly,  but  general  symptoms,  apparently  similar,  may 
proceed  from  opposite  causes,  and  the  diet  that  may 
benefit  one  will  aggravate  the  trouble  in  another.  Again, 
under  treatment,  the  gastric  conditions  change  from  time 
to  time,  demanding  that  the  effects  of  the  diet  should  be 
carefully  watched,  and  the  diet  itself  modified  accordingly. 

Many  stomach  specialists  use  certain  diet-lists  as  a 
routine  treatment  in  given  conditions,  and  these  are  avail- 
able in  various  text-books.  A  nurse  should  be  very  careful 
not  to  encourage  the  use  of  such  lists  except  under  expert 
advice,  since,  without  accurate  knowledge  of  the  condition, 


DIET   IN   SPECIAL   DISEASES  793 

even  careful  dieting  is  merely  hit  or  miss.  To  take  a  case 
in  point:  In  gastric  disorders  the  gastric  juice  is,  to  a  greater 
or  less  extent,  changed.  There  may  be  an  increase  of  acid- 
ity, or  there  may  be  a  decrease  or  even  an  absence  of 
acidity  (p.  258).  The  symptoms  that  are,  however,  ap- 
parent to  the  patient  or  the  nurse  may  seem  to  be  the  same 
in  either  case.  Obviously,  the  diet  that  will  suit  one  case 
will  not  be  best  suited  to  the  other.  In  the  first  case,  since 
the  use  of  the  hydrochloric  acid  is  in  the  digestion  of  the 
proteins,  the  excess  of  acid  may  be  in  some  cases  counter- 
acted by  a  diet  in  which  the  proteins  are  pushed  at  the 
expense  of  the  carbohydrates ;  in  the  second,  protein  diges- 
tion is  faulty;  the  protein  foods  are  given  sparingly,  in  the 
most  digestible  forms,  and  their  place  largely  taken  by 
carbohydrate  foods  and  fats.  In  other  cases  it  may7  be 
the  muscular  power  of  the  stomach  that  is  at  fault,  as  in 
dilated  stomach.  In  this  condition  the  restriction  of  fluids 
is  a  most  important  part  of  the  diet,  and  a  diet,  however 
digestible,  in  which  broths  and  milk  are  given  freely,  may 
simply  increase  the  disorder. 

The  object  of  a  special  diet  in  these  conditions  may  be 
put  briefly  as  a  means  of  giving  the  body  the  amount  of 
nourishment  necessary,  with  the  least  possible  work  for 
the  faulty  digestive  organs;  whatever  part  of  the  digestive 
tract  is  out  of  order,  therefore,  must  be  given  the  least 
amount  of  work.  At  the  same  time  the  five  food-elements 
must  be  represented. 

Here  again  the  importance  of  an  estimation  of  the  caloric 
value  of  a  given  diet  is  demonstrated,  so  that  the  best  re- 
sults may  be  obtained  with  the  least  work  for  the  diges- 
tion. Usually,  35  calories  for  each  kilogram  of  the  weight 
is  allowed  if  the  patient  is  confined  to  bed,  or  40  if  he  is 
about  doing  light  work.  During  the  entire  treatment  the 
patient  must  be  regularly  weighed. 

In  the  acute  stage  of  any  gastric  disorder  the  first  aim  is 
to  give  the  digestive  tract  as  little  work  as  possible,  fre- 
quently at  the  cost  of  temporarily  starving  the  body. 

In  chronic  conditions,  especially  where  the  patient  is 
about  and  leading  an  ordinary  life,  it  is  necessary  that  he 
should  have  the  amount  of  food  to  keep  up  his  body  weight, 


794  DIETS   AND   DIETING 

which  is  the  practical  sign  that  the  body  is  getting  and 
using  its  due  amount  of  nourishment. 

Acute  Digestive  Disorders. — In  any  acute  gastric  or 
intestinal  condition  we  begin,  probably,  with  a  period  of 
starvation,  following  which  food  in  its  most  digestible  form 
is  given,  i.  e.,  milk  and  milk  preparations,  broths,  and  egg- 
albumin,  and,  finally,  gradually  adding  solid  foods  as  they 
can  be  borne.  The  choice  of  diet  is  governed  by  local  symp- 
toms. Thus,  if  diarrhea  is  present,  foods  with  a  constipat- 
ing quality  are  necessary  until  the  condition  is  arrested. 
Such  are  boiled  milk,  milk  with  lime-water,  corn  flour  or 
arrowroot  gruels,  barley-water  or  rice-water — the  two  lat- 
ter for  their  mildly  astringent  action.  If  constipation  is 
present,  buttermilk  or  whey  is  preferred  to  milk;  and,  as  a 
rule,  fats  in  some  form  will  be  ordered  probably  as 
cream. 

Gastric  Ulcer. — In  some  acute  conditions  the  diet 
treatment  may  be  carried  over  several  weeks,  as,  for  ex- 
ample, in  gastric  or  duodenal  ulcer.  Beginning  with 
milk,  broths,  and  raw  eggs,  given  in  small  quantities, 
some  easily  digested  solids  are  added  at  regular  intervals, 
usually  of  ten  or  fifteen  days.  In  the  most  aggravated 
conditions,  as  in  ulcer  associated  with  hemorrhages,  food 
cannot  be  given  by  mouth  at  all,  and  is  replaced  by  rectal 
feeding  during  the  acute  stage. 

An  average  scheme  of  diet  frequently  ordered  in  gastric 
or  duodenal  ulcer  is  as  follows: 


First  two  weeks  (daily  quantity) :  Milk,  half  a  pint;  chicken  or 
mutton  broth,  half  a  pint;  plain  crackers,  4  to  6;  white  of  one  egg 
in  milk  or  water.  Water,  one  pint,  is  added,  either  used  to  dilute 
the  milk  or  given  in  addition.  The  foods  are  given  in  equal  amounts, 
every  two  hours  the  first  week,-  then  in  larger  portions  every  three 
hours.  Liquids  should  be  given  cool — either  extreme  of  temperature 
may  aggravate  the  condition. 

Second  two  weeks:  To  the  above  add  gruel  of  cornmeal  or  tapioca 
with  cream;  puree  of  potatoes  or  peas;  white  of  egg  2  (making  3), 
chocolate  blancmange,  jelly,  junket,  soft-boiled  egg,  custard,  2  zwie- 
back, or  dry  toast.  Any  of  these  are  added,  first  once  a  day,  at  the 
midday  meal,  beginning  with  small  quantities,  then  as  borne  twice 
and  three  times,  reducing  the  intermediate  feedings  accordingly,  and 
increasing  the  quantity  until  an  ordinary  "  helping  "  is  reached.  The 
quantity  should  always  be  measured. 

Third  two  weeks:  Add  scraped  beef  (3  ounces);  finely  minced 


DIET   IN   SPECIAL   DISEASES  795 

chicken  (3  ounces);  broiled  tender  beef -steak  (3  ounces),  or  a  tender 
pigeon,  broiled;  later  add  mashed  potatoes  and  asparagus-tips  or 
cauliflower  (flower  only),  cooked  until  soft. 

From  sixth  to  eighth  week:  Gradually  introduce  broiled  chops, 
beef-steak  (rare),  whitefish,  cooked  eggs,  macaroni,  puddings  of  rice, 
tapioca,  and  corn -starch,  and  strained  apple-sauce. 

After  the  eighth  week  resume  ordinary  diet,  avoiding  coarse  vege- 
tables, fried  foods,  gravies  and  condiments,  and  either  ice-cold  or 
very  hot  foods  or  drinks. 


Diarrhea,  Dysentery  (Acute). — Before  any  diet  is  begun, 
the  patient  is  purged  and  starved  twenty-four  hours; 
sips  of  tepid  water  may  be  given  to  allay  the  thirst,  or  ice 
may  be  slowly  sucked,  but  even  water  should  be  as  re- 
stricted as  possible. 

At  the  present  day  milk  in  any  form  is  avoided  during  the 
acute  stage,  i.  e.,  as  long  as  there  is  any  pain,  tenesmus,  or 
rise  of  temperature.  Albumin  water  and  strained  chicken 
or  mutton  broth  are  given — two  pints  in  all  in  the  twenty- 
four  hours.  Some  doctors  order  tender,  lightly  broiled 
lean  meat  or  scraped  beef  at  an  early  stage.  As  the  con- 
dition improves,  well-cooked  barley  or  rice  or  dry  toast  is 
added  to  the  broths,  skimmed  milk,  or  whey;  later,  far- 
inaceous puddings,  tapioca,  rice,  etc. ;  soft-boiled  eggs  and 
rusks.  When  all  symptoms  have  disappeared,  butter  and 
cream  are  added  with  caution,  and  the  ordinary  diet  is 
gradually  resumed,  beginning  with  lean,  finely  divided 
meats  in  small  quantities,  and  avoiding  coarse  vegetables, 
fried  or  seasoned  foods,  and  extremes  of  temperature,  es- 
pecially in  drinks. 

Diarrhea  in  Infancy. — Diarrhea  in  young  children  is 
always  an  important  symptom,  even  when  slight;  in  its 
severe  form,  accompanied  by  high  fever,  acute  colic,  and 
rapid  waste  of  the  tissues,  with  profound  prostration, 
it  is  one  of  the  most  fatal  disorders  of  infancy.  The  treat- 
ment is  largely  dietetic. 

Castor  oil  is  usually  given  first  as  a  purge,  and  all  food 
withheld  for  twenty-four  hours.  Sips  of  tepid  water  may 
be  given  if  there  is  no  vomiting;  if  vomiting  is  present  and 
thirst  is  excessive,  the  mouth  is  washed  with  weak  lemon- 
juice  and  water,  or  shavings  of  ice  are  placed  in  the  mouth. 
Lavage  and  enteroclysis  of  sterile  water  are  also  often 


796  DIETS  AND   DIETING 

ordered,  or,  if  collapse  is  threatened,  hypodermoclysis  of 
normal  salt  solution. 

Milk  is  avoided  entirely — indeed,  is  looked  on  as  actually 
poisonous.  After  twenty-four  hours  egg-albumen  is  added 
to  the  water,  beginning  with  half  an  egg  in  twenty-four  hours 
and  increasing  to  two  eggs  if  well  borne.  Small  feedings 
(|  to  2  ounces)  of  well-cooked  barley-water  or  rice-water 
are  added  as  the  condition  improves.  Of  the  next  step 
there  are  a  variety  of  opinions:  at  present  predigested 
foods  in  some  form  are  in  favor,  such  as  malted  milk,  cereo- 
barley,  Benger's  or  Mellin's  food,  and  panopeptone  in 
water.  Milk  is  usually  reintroduced  first  as  whey,  one 
feeding  in  the  twenty-four  hours.  Peptonized  milk  with 
equal  parts  of  barley-water  is  favored  by  some.  Chicken 
and  veal  tea,  with  all  fat  carefully  removed,  are  frequently 
ordered.  Fat,  in  the  form  of  cream,  is  not  added  until  all 
symptoms  have  disappeared  and  convalescence  is  estab- 
lished. Many  doctors  withhold  milk  entirely  for  some 
weeks;  others  begin  with  a  weak  modified  milk  as  soon  as 
convalescence  has  set  in,  and  gradually  build  up  until  the 
usual  diet  is  resumed. 

In  older  children  the  return  to  solid  diet  is  made  with 
chicken  or  veal  tea,  thickened  with  well-cooked  barley  or 
rice,  or  eaten  with  dry  toast,  soft-boiled  eggs,  and  farina- 
ceous puddings.  Milk  may  be  given,  first  boiled  with 
rusks  or  toast.  Fruit,  vegetables,  and  cereals  are  with- 
held until  the  child  is  perfectly  well,  and  butter  used  spar- 
ingly. 

In  all  these  cases  very  accurate  records  of  the  diet  taken 
should  be  kept  and  charted  with  the  records  of  the  tem- 
perature, etc.,  the  bowel  movements,  and  the  weight. 
The  child  is  usually  weighed  daily.  Every  stool  must  be 
carefully  inspected. 

Chronic  Digestive  Disorders. — As  has  been  said,  it  is 
impossible  to  lay  down  any  rules  for  the  diet  of  the  large 
variety  of  chronic  gastric  or  intestinal  disorders.  The  ob- 
ject of  dieting  is  to  give  food  that  will  cause  least  trouble 
to  the  damaged  part  of  the  digestive  tract,  that  will 
not  aggravate  existing  trouble,  and  that,  with  a  minimum 
amount  of  work  for  the  digestive  organs,  the  required 


DIET   IN   SPECIAL   DISEASES  797 

amount  of  energy  should  be  gained.  At  the  same  time, 
in  order  to  get  the  digestion  into  perfect  working  order, 
it  is  probably  necessary  to  tone  the  damaged  part  with  light 
work,  gradually  increasing  the  work  as  the  condition  im- 
proves. It  may  be  necessary  to  begin  with  predigested 
foods,  either  proprietary  foods  or  peptonized  milk,  broths, 
or  gruels.  As  a  rule,  these  are  dispensed  with  as  soon  as 
possible,  in  order  to  stimulate  the  natural  secretions  with 
a  more  normal  diet. 

The  choice  of  food  depends  on  the  local  condition,  on 
the  digestibility  of  the  food,  and  on  its  caloric  value. 
Nurses  may  well  be  given  practice  in  working  out  tables 
of  the  caloric  value  of  the  most  digestible  of  the  various 
food-stuffs  and  preparations,  and  in  contriving  diet  tables 
of  a  given  number  of  calories  in  which  the  proportion  of 
protein,  carbohydrates,  and  fats  are  varied  from  different 
causes.  Remembering  that  35  to  40  calories  may  be 
given  per  diem  for  each  kilogram  of  the  patient's  weight, 
and  given  the  necessary  proportion  of  protein,  fats,  and 
carbohydrates,  the  weight  of  the  patient,  and  a  knowledge 
of  what  food  forms  are  most  digestible,  a  nurse  should  be 
able  to  produce  a  diet  from  day  to  day  to  suit  the  needs 
of  the  patient,  without  too  much  monotony. 

Where  hyperacidity  is  present,  protein  foods  are  usually 
ordered  in  excess  to  counteract  the  condition.  All  forms 
of  lean,  tender  meat  are  given,  eggs,  and  cereals  and  vege- 
tables with  a  high  protein  percentage,  such  as  oatmeal, 
and  cornmeal,  mashed  potatoes,  and  purees  of  peas, 
beans,  and  lentils.  Toast  and  rusks  are  the  most  digestible 
form  in  which  white  bread  can  be  taken. 

In  cases  of  deficient  gastric  secretion  the  proteins  are 
given  sparingly  and  in  the  most  digestible  forms.  The 
meats  preferred  are  broiled  sweetbread,  broiled  tenderloin 
steak,  and  white  meat  of  young  chicken,  all  in  small  quan- 
tities. The  best  cereals  are  wheat  and  rice,  in  which  the 
percentage  of  protein  is  low;  mashed  potatoes  and  well- 
cooked  asparagus-tips  or  cauliflower  (flower  only)  are 
generally  the  vegetables  preferred. 

Milk  is  valuable  in  either  condition,  and  pains  should 
be  taken  to  find  the  form  in  which  it  is  most  digestible. 


798  DIETS  AND   DIETING 

It  should  be  taken  between  the  heavier  meals,  with  nothing 
more  solid  than  a  biscuit.  Tea  and  coffee  are  frequently 
forbidden;  if  allowed,  they  should  be  weak,  freshly  made, 
and  allowed  to  cool  before  they  are  taken.  They  should 
only  be  allowed  with  the  light  meals.  Water  is  usually 
ordered  between  meals,  and  drinking  altogether  forbidden 
at  the  more  §olid  meals. 

Fat  in  some  form  is  a  necessary  part  of  the  diet.  It  is 
given  as  butter  or  cream,  or  sometimes  as  chocolate,  but 
should  be  used  very  sparingly  in  the  preparation  of  the 
food. 

In  these  conditions  the  appetite  is  not  a  guide  to  the 
amount  of  food.  Some  patients  loathe  their  food,  others 
are  ravenous  and  overload  the  digestion.  The  food 
should  be  carefully  weighed  and  measured,  and  the  patient 
gradually  accustomed  to  the  required  amount. 

The  usual  rule  is  to  give  small  meals  at  frequent  inter- 
vals, with  the  heaviest  meal  in  the  middle  of  the  day. 
Patients  should  eat  slowly,  masticate  thoroughly,  and  rest 
for  a  short  time  after  each  meal. 

For  the  diet  in  dilatation  of  the  stomach  the  same 
rules  are  observed,  according  to  the  condition  of  the  gas- 
tric secretion.  The  special  feature  in  this  condition  is  the 
restriction  of  the  fluids.  This  often  causes  much  distress, 
which  may  be  relieved,  to  some  extent,  by  rectal  infusion 
of  sterile  water.  In  many  cases  daily  lavage  of  sterile 
water  is  a  routine  part  of  the  treatment. 

Obstruction  of  the  Bile-ducts. — In  these  conditions,  as 
from  gall-stones,  inflammation,  or  organic  disease,  the  bile 
may  be  greatly  diminished  in  quantity  or  entirely  absent 
from  the  digestive  tract.  In  the  diet  for  such  a  condition 
the  fats  are  omitted,  since,  as  we  remember,  the  bile 
plays  an  important  part  in  the  digestion  and  absorption 
of  fats. 

Peptonized  milk,  buttermilk,  whey,  or  milk  diluted 
with  natural  mineral  waters,  are  given  during  an  acute 
attack.  Hot  water  should  be  given  freely;  it  helps  to 
purge  the  alimentary  tract,  and  counteract  the  constipa- 
tion due  to  the  absence  of  bile,  and  aggravated  by  the 
lack  of  fats.  When  solids  can  be  borne,  lean  broiled  meats, 


DIET   IN   SPECIAL   DISEASES  799 

sweetbreads,  whitefish,  baked  potato,  crackers,  and  toasted 
bread  are  gradually  added;  fats,  butter  and  cream,  or 
fried  dishes,  should  not  be  allowed  until  the  patient  is 
completely  recovered. 

Chronic  Constipation. — The  dietary  causes  of  constipa- 
tion are  insufficient  proportion  of  fluids,  lack  of  fats  and 
oils  or  organic  salts,  excessive  use  of  alcohol,  or  the  use 
of  foods  that  are  almost  entirely  digested  (such  as  milk  and 
eggs),  and  leave  no  residue  to  act  as  irritants  to  the  intes- 
tinal walls  and  induce  peristalsis.  Water  should  be  taken 
freely  between  meals,  and  especially  at  bedtime  and  before 
breakfast,  cold  water  being  preferred,  as  it  excites  peris- 
talsis. The  diet  should  include  foods  that  leave  some 
indigestible  residue,  such  as  oatmeal,  cornmeal,  whole- 
wheat and  bran  bread,  coarse  vegetables,  berries,  and  figs; 
bland,  non-exciting  food,  such  as  milk  and  eggs,  should  be 
restricted.  To  some  people  milk  is  constipating;  on  others 
it  has  a  laxative  effect,  especially  if  rich  in  cream.  Its  use 
must  be  governed  by  the  individual  effects. 

Olive  oil  taken  regularly,  a  dessertspoonful  three  or 
four  times  a  day,  is  often  successful  in  relieving  constipa- 
tion, and  almost  all  fruits  are  beneficial,  especially  apples 
and  prunes.  They  are  most  efficacious  if  taken  first  thing 
in  the  morning.  Alcohol  should  be  given  up.  Tea  may 
cause  constipation,  on  account  of  the  tannin  it  contains; 
on  the  other  hand,  the  amount  of  fluid  ingested  is  helpful ; 
coffee  is  preferable  as  a  morning  beverage,  as  it  contains  a 
certain  amount  of  oil.  Buttermilk  may  be  used  as  a  bever- 
age with  good  effect,  as  it  usually  acts  as  a  mild  laxative. 
Molasses  and  honey  are  also  considered  laxative,  and  may 
be  given  with  whole-wheat  breads. 

Nephritis  (Inflammation  of  the  Kidneys). — As  the  excre- 
tion of  urea  and  its  elimination  from  the  body  is  the  func- 
tion of  the  kidneys,  it  is  not  effectually  performed  where  the 
kidneys  are  not  in  a  normal  condition  of  activity.  If  we 
give  an  ordinary  amount  of  protein  food  in  such  conditions, 
we  may  cause  the  system  to  become  overloaded  with  urea 
(which  we  remember  is  the  residue  of  protein  combustion), 
and  we. also  further  overtax  the  diseased  kidneys.  In  all 
conditions  associated  with  irritation  or  disease  of  the  kid- 


8UO  DIETS  AND   DIETING 

neys  we  therefore  give  a  minimum  supply  of  protein  food, 
in  order  both  to  rest  the  kidneys  and  to  diminish  the 
amount  of  urea  formed  in  the  body. 

In  acute  cases  of  nephritis  an  exclusive  milk  diet  is 
generally  ordered;  when  it  becomes  necessary  to  reinforce 
this,  carbohydrate  food  is  added  in  the  form  of  gruels, 
bread  and  butter,  rice,  and  farinaceous  foods.  This  is 
continued  until  the  urine  is  normal,  and  shows,  on  examina- 
tion, no  trace  of  albumin.  (See  Urine.) 

In  chronic  cases  of  nephritis  it  is  not  practical  to  reduce 
the  protein  foods  permanently,  and  a  more  varied  diet  is 
given.  Meat  is  usually  taken  with  the  principal  meal  of 
the  day;  the  diet  includes  eggs,  fish,  most  vegetables  (ex- 
cept asparagus,  celery,  garlic,  and  leeks),  and  simple 
desserts.  All  spices  and  hot  condiments,  such  as  pepper, 
mustard,  curry,  etc.,  must  be  carefully  avoided.  Tea, 
coffee,  and  usually  alcoholic  drinks  are  either  forbidden 
or  their  use  restricted.  Headache,  vertigo,  and  disturb- 
ances of  vision  may  be  indications  of  an  accumulation  of 
urea,  and,  when  noticed,  the  protein  foods  should  be  dis- 
continued temporarily  and  the  system  purged. 

Water  and  simple  beverages  should  be  taken  freely, 
unless  in  conditions  of  dropsy,  where  fluids  are  usually 
restricted.  Imperial  drink  is  valuable,  both  in  acute  and 
chronic  conditions  of  nephritis.  (See  Recipe.) 

Dropsy. — In  conditions  associated  with  dropsy, "  either 
in  nephritis  or  cardiac  disease,  improvement  has  been  found 
to  follow  restriction  of  the  amount  of  common  salt  in  the 
diet.  In  the  average  diet,  between  ten  and  twenty  grams 
of  salt  are  taken  in  the  food-stuffs  and  as  seasonings.  Ac- 
cording to  the  severity  of  the  case,  the  amount  of  salt 
allowed  is  restricted  or  altogether  omitted.  At  the  same 
time  the  liquids  are  reduced. 

The  strict  salt-free  diet  commonly  ordered  consists  of  the 
following  articles: 

Bread  baked  without  salt  and  eaten  with  fresh,  salt-free 
butter  or  clotted  cream.  Rice,  barley,  tapioca,  or  sago, 
well  cooked  and  eaten  with  cream  and  sugar  or  molasses, 
mashed  potatoes  without  salt,  eaten"  with  fresh  butter, 
eggs,  two  to  four  per  diem,  usually  soft-boiled  and  eaten 


DIET   IN    SPECIAL  DISEASES  801 

without  salt.  A  small  amount  of  certain  fruits,  orange, 
grape-fruit,  or  grapes,  is  allowed  daily. 

Not  more  than  one  pint  of  liquids  is  taken  daily — gen- 
erally milk  diluted  with  Vichy  and  some  water. 

The  quantities  are  prescribed  to  suit  the  case.  Where 
a  more  liberal  diet  is  permissible,  as  in  chronic  cardiac 
affections,  meats  cooked  without  salt,  fresh-water  fish, 
vegetables,  salads,  and  fruits,  both  raw  and  cooked,  all 
without  salt,  are  added,  with  salt-free  cheese  and  simple 
desserts.  The  food  must  be  given  in  its  most  digestible 
form,  since  in  omitting  salt  we  omit  one  of  the  aids  to  di- 
gestion. 

Oxaluria  (calcium  oxalate  in  the  urine)  is  a  symptom 
associated  with  gout,  certain  forms  of  rheumatism,  and 
many  nervous  disorders.  Acid  fruits  and  vegetables  ag- 
gravate the  condition.  The  diet  excludes  tomatoes, 
rhubarb,  plums,  and  all  berries,  either  raw  or  cooked; 
spinach,  cauliflower,  green  beans,  and  potatoes;  cocoa 
and  chocolate.  Tea,  coffee,  and  alcohol  are  either  for- 
bidden or  their  use  strictly  limited.  The  food  must  be 
simply  cooked,  avoiding  rich  dishes,  spices,  and  seasonings. 

Diabetes  Mellitus  (Glycosuria). — No  disease  depends 
for  its  treatment  so  entirely  on  diet  as  diabetes,  which  is 
characterized  by  the  persistent  presence  of  grape-sugar 
(dextrose,  one  of  the  glucoses)  in  the  urine,  and  the  passing 
of  large  quantities  of  urine  of  a  high  specific  gravity. 

In  the  diet  all  the  carbohydrates  are,  as  far  as  possible, 
eliminated,  the  food-stuffs  comprising  only  proteins, 
fat,  water,  and  salts. 

The  proteins  given  are  derived  entirely  from  animal 
foods.  All  meats  and  fish  are  allowed  except  liver,  oysters, 
and  other  mollusks  in  which  glycogen  is  found  (Chap. 
XXI).  Milk,  eggs,  and  cheese  are  allowed. 

Fats  are  given  in  excess,  in  order  to  make  up  for  the  loss 
of  carbohydrates.  Cream,  butter,  bacon-fat,  and  the  fats 
of  other  meats  are  an  important  part  of  a  diabetic  dietary. 
Olive  oil  and  all  nuts,  for  the  oil  they  contain,  may  be 
used,  provided  they  are  well  digested.  In  choosing  vege- 
tables, those  rich  in  carbohydrates  must  be  omitted.  This 
excludes  cereals,  tubers,  and  legumes,  but  leaves  all  green 

51 


802  DIETS   AND   DIETING 

vegetables,  radishes,  onions,  cucumbers,  tomatoes,  and 
rhubarb.  Acid  fruits  are  permitted  in  limited  quantities, 
such  as  apples,  currants,  cranberries,  lemons,  oranges, 
grape-fruit,  plums,  etc.  Desserts  sweetened  with  cane- 
sugar,  cocoa,  chocolate,  and  all  sugary  foods  are,  of  course, 
excluded. 

The  chief  difficulty  in  a  diabetic  diet  is  to  find  a  sub- 
stitute for  bread.  Patent  breads,  made  of  gluten  flour, 
almond  flour,  bean  meal,  and  bran  flour,  are  used,  but 
rarely  satisfy.  Their  use  even  must  be  limited,  since  they 
all  contain  some  starch.  Some  doctors  allow  a  small 
quantity  of  white  bread  once  or  twice  a  day,  except  in 
acute  conditions. 

Instead  of  cane-sugar,  saccharin,  a  coal-tar  product, 
is  used  to  sweeten  foods  when  necessary.  It  is  said  to  be 
300  times  as  sweet  as  cane-sugar.  Many  diabetics,  how- 
ever, prefer  unsweetened  food  to  the  use  of  saccharin. 
If  alcohol  is  necessary,  usually  the  sour  Rhine  wines  are 
ordered,  or  brandy,  which  helps  in  the  digestion  of  fats. 
Spices  and  condiments  of  all  sorts  can  be  taken. 

A  diet  of  proteins  and  fats  results  in  the  formation  of 
acids  in  the  body,  which,  if  allowed  to  accumulate,  will 
cause  acid  poisoning  and  fatal  diabetic  coma.  It  is,  there- 
fore, very  necessary  that  the  bowels  of  diabetic  patients 
should  be  kept  open  and  acting  regularly.  Water  and  un- 
sweetened beverages  may  be  taken  as  freely  as  desired. 
The  urine  should  be  examined  at  intervals ;  acetonuria  is  a 
warning  of  the  approach  of  diabetic  coma,  which  may  be 
averted  if  dietetic  treatment  is  prompt. 

Phthisis. — At  the  present  day,  most  people  realize  that  a 
prominent  part  of  the  treatment  of  all  forms  of  tuberculosis 
consists  in  a  well-balanced  dietary  of  easily  digested  foods. 
A  larger  amount  of  food  than  is  necessary  in  the  normal 
condition  is  required  to  increase  the  resistance  of  the  body 
to  the  disease  and  to  repair  the  tissue  waste.  A  well- 
mixed  diet  of  a  somewhat  raised  caloric  value  is  usually 
prescribed.  To  avoid  indigestion,  this  is  given  in  easily 
digested  and  concentrated  forms.  The  most  valuable 
articles  in  a  consumptive's  diet  are  milk,  cream,  and  eggs. 
Milk  is  taken  between  the  meals,  and  with  the  lighter  meal 


DIET    IX   SPECIAL   DISEASES  803 

— either  breakfast  or  supper;  eggs,  as  a  rule,  are  taken  raw. 
In  this  way  they  are  not  actually  so  easily  digested  as 
when  lightly  boiled,  but  as  the  patient  tires  less  easily 
of  them,  more  can  be  taken  over  a  greater  length  of 
time.  From  8  to  18  are  often  consumed  daily  without 
causing  indigestion.  Fats  and  oils  are  also  of  value,  and 
in  the  phthisis  dietary  largely  replace  carbohydrates. 
They  are  more  highly  concentrated,  have,  bulk  for  bulk, 
twice  the  caloric  value,  and,  further,  they  help  to  correct 
the  constipation  that  commonly  results  from  any  large 
consumption  of  milk  and  eggs.  Fats  are  given  in  the  form 
of  cream,  bacon-fat,  olive  oil,  and  the  fat  of  various  meats. 

Scurvy. — Scurvy  is  directly  due  to  a  deficiency  of 
organic  salts,  and  results  from  a  diet  in  which  milk,  fresh 
meat,  vegetables,  and  fruit  have  not  been  included. 

In  adults,  fresh  meat,  vegetables,  milk,  and  the  juice  of 
oranges  and  lemons  are  ordered.  When  sailors  have  to 
be  long  away  from  supplies  of  fresh  food,  lemon-juice, 
onions,  and  vinegar  are  taken  as  preventives. 

In  infants,  scurvy  is  most  frequently  the  result  of  using 
sterilized  milk,  condensed  milk,  or  some  of  the  proprietary 
infant's  foods.  A  diet  of  fresh  milk,  beef-juice  (1  dram  to 
1  ounce  daily),  and  orange-juice  (1  ounce  to  4  ounces 
daily)  is  usually  sufficient  to  correct  the  condition.  Beef- 
juice  is  not  given  until  after  the  tenth  month,  and  is  con- 
traindicated  if  the  intestines  are  in  an  irritated  condition. 

Rickets. — Rickets  is  a  disease  of  young  life,  the  result  of 
a  deficiency  of  lime  salts,  in  consequence  of  which  the  bones 
become  soft  and  deformed.  It  is  generally  caused  by  a 
diet  containing  too  little  protein  and  fat  and  too  large  a 
proportion  of  carbohydrates,  as  is  frequently  the  fault  in 
proprietary  foods. 

A  liberal  diet,  including  fresh  milk,  egg-albumen,  and 
beef-juice,  broths,  or  fresh  meat,  if  the  child  is  old  enough, 
is  necessary.  At  the  same  time  fresh  air  and  good  hygiene 
are  equally  important.  Fat  in  the  form  of  cream,  butter, 
and  bacon-fat  should  be  given.  Cod-liver  oil  is  often 
ordered,  and  usually  some  preparation  of  the  phosphates, 
such  as  the  syrup  of  the  hypophosphites  (5  to  15  minims). 

In  anemia  the  quality  and  composition  of  the  blood  is 


804  DIETS   AND   DIETING 

altered,  and  there  is  a  marked  deficiency  of  the  red  color- 
ing-matter or  hemoglobin. 

The  diet  must  be  liberal,  nourishing,  and  digestible. 
It  should  include  concentrated  nourishing  foods,  especially 
eggs,  beef-juice,  or,  if  the  digestion  permits,  rare  tender 
beef-steak  and  other  meats;  milk,  cream,  butter,  bacon- 
fat,  and  well-cooked  cereals.  Nourishing  soups  are  also 
given,  and  vegetables,  especially  green  vegetables,  on  ac- 
count of  their  mineral  salts.  Spinach,  which  contains 
iron,  is  particularly  suitable. 

Anemic  girls  have  often  very  capricious  appetites  and 
abnormal  cravings  for  such  articles  as  chalk,  earth,  etc. 
Others  enlist  sympathy  by  pretending  to  be  unable  to  eat, 
and  satisfying  their  appetites  in  secret.  In  these  cases  the 
patient  may  require  close  watching,  and  the  right  diet  may 
have  to  be  forced. 


CHAPTER  XXIV 

THE  HEAD  NURSE  AND  WARD  MANAGEMENT 

Division  of  Duties — Orderly — Ward-maid — Time-table — Report- 
ing— Stock-book  and  Inventories — Linen  Supply — Blankets — Pa- 
tients' Effects — Special  Duties  of  a  Head  Nurse — Patients'  Visitors — 
Domestic  Work:  Sweeping,  Mopping,  Scrubbing,  Polishing,  Dust- 
ing, Care  of  Enamelware,  Glass,  Porcelain,  Marble,  Polished  Furni- 
ture, Stains  on  Wood,  Saucepans  and  Kitchenware,  Ice-chest,  Brass 
and  Copper — Beds  and  Bedding — Ward  Ventilation  and  Tempera- 
ture— The  Visiting  Rounds. 

AN  essential  quality  of  a  successful  head  nurse  is  execu- 
tive ability.  While  in  a  well-organized  hospital  the  lines 
are  already  set  in  which  the  work  must  run,  most  days  will 
bring  fresh  circumstances,  which  alter  conditions  so  mater- 
ially that  unless  rules  and  orders  are  promptly  adapted  to 
meet  them,  confusion,  rushed  work,  and  overwork  of  the 
most  willing  are  the  result. 

On  her  shoulders  falls  the  responsibility  of  carrying  on 
the  daily  work  adequately  and  without  friction;  of  ad- 
ministering the  domestic  side  of  ward  work;  of  insuring 
the  proper  fulfilment  of  all  orders  for  treatment;  of  preserv- 
ing the  equipment,  instruments,  etc.,  in  her  charge  in  good 
condition;  of  keeping  up  supplies  and  preventing  waste  in 
their  use;  of  the  physical  and  mental  well-being  of  the 
patients  under  her  care.  At  the  present  day  she  is  not 
often  held  responsible  for  the  actual  instruction  of  the 
pupil  nurses,  but,  as  a  matter  of  practical  experience,  we 
know  no  teaching  impresses  itself  more  forcefully  on  the 
pupil  than  that  gleaned  from  the  practice  and  example  of  a 
ward  head  nurse,  from  her  manner  and  attitude  toward 
patients,  workers,  doctors,  and  visitors  to  the  standards 
of  work  required  by  her  from  each  pupil  working  under 
her.  "  As  the  twig  is  bent  so  the  tree  is  inclined";  a 
nurse's  work  will  carry  through  life  something  of  the 
impress  of  the  first  wards  in  which  she  practised  her  duties. 

805 


806   THE  HEAD  NURSE  AND  WARD  MANAGEMENT 

In  the  present  chapter  we  should  like  briefly  to  suggest, 
from  our  personal  experience,  some  methods  in  which  the 
practical  work  of  a  head  nurse  can  be  so  ordered  as  to  be 
both  simplified  for  herself  and  of  wide-reaching  use  and 
comfort  to  others. 

DIVISION   OF  LABOR 

From  the  early  days  of  her  training  the  pupil  nurse 
should  be  given  some  responsibility,  and  that  one  duty, 
however  small,  be  used  as  a  training-ground  in  thorough- 
ness, punctuality,  and  in  observation,  as  well  as  in  the 
acquiring  of  a  sense  of  responsibility,  without  which  she 
will  never  be  a  reliable  worker. 

In  arranging  a  schedule  of  work  among  several  nurses 
the  duties  are  graded  according  to  the  progress  of  the  indi- 
vidual training,  the  more  responsible  forms  of  treatment 
being  given  to  the  senior,  and  the  simplest  duties  to  the 
newest  comers.  At  the  same  time  many  duties  should  be 
common  to  all,  and  others  of  monotonous  routine  may,  with 
advantage,  be  interchangeable  from  week  to  week.  It  is  no 
uncommon  thing,  where  nurses  are  left  to  divide  their  own 
minor  duties,  to  find  the  youngest  worker  passing  her 
entire  time  in  an  accumulation  of  monotonous  and  profit- 
less routine  duties,  tiring  to  body  and  spirit,  while  the 
senior  nurse  performs  not  the  smallest  minor  duty  and 
usually  ends  by  considering  such  duties  beneath  her  dignity. 

While  the  nursing  of  the  patient  is  the  most  important 
part  of  our  work,  to  make  such  distinctions  in  any  neces- 
sary duty  connected  with  the  care  of  the  sick  shows  a  lack 
of  common  sense  and  results  in  harm.  Is  it  not  the  first 
step  toward  that  attitude  that  makes  people  say,  too  often 
justly,  "  A  nurse  wants  so  much  waiting  upon." 

No  definite  lines  can  be  laid  down  as  to  the  division 
of  work,  since  it  must  depend  on  the  amount  of  the 
work,  the  kind  of  the  work,  whether  medical,  surgical, 
children's,  or  special  nursing,  whether  in  a  general  ward 
or  private  rooms,  and  must  always  be  modified  by  the 
hospital  construction  or  the  number  of  workers.  A  sug- 
gested outline  may,  however,  be  helpful. 

In  some  wards  each  nurse  is  given  a  certain  number  of 


DIVISION    OF    LABOR 

"  beds,"  and  the  absolute  charge  of  those  patients,  making 
their  beds,  attending  to  all  their  wants,  giving  them  their 
meals,  their  medicines,  and  carrying  out  all  their  treatment. 

When  the  patients  are  in  single  rooms,  as  with  private 
patients,  this  is  almost  necessary,  and  in  children's  nursing 
the  system  also  works  well,  as  all  children,  whether  very 
sick  or  convalescent,  require  a  great  deal  of  individual  care 
and  attention. 

In  general  ward  work  the  patients  should  be  so  divided, 
to  a  certain  extent,  that  is  to  say,  for  their  bed-making, 
washing,  and  routine  treatment  (such  as  douching,  etc.), 
to  avoid  the  discomfort  for  the  patient  of  constant  change ; 
at  the  same  time,  in  an  open  ward,  all  the  nurses  are  familiar, 
and  for  one  nurse  to  take  his  temperature  and  another  to 
give  his  medicine  or  his  food  does  not  mean  for  a  ward 
patient  a  perpetual  fresh  face,  as  it  would  for  one  in  a  pri- 
vate room. 

When  possible,  the  patients  in  a  nurse's  immediate  charge 
should  be  grouped  together,  in  order  to  save  her  steps, 
and  that  she  may  readily  be  within  call  of  each;  she  should 
then  be  held  responsible  for  the  neatness  and  cleanliness  of 
that  particular  division  of  the  ward,  with  the  lockers,  bed- 
tables,  and  personal  effects  of  her  patients.  Where  the 
cases  are  acute,  a  smaller  number  should  be  given  to  a 
nurse  than  where  the  cases  are  mild  or  convalescent. 

It  is  usually  a  mistake  to  give  a  junior  nurse  only  conva- 
lescent cases.  If  she  is  in  earnest  over  her  work,  a  few 
weeks  will  teach  a  nurse  the  actual  handling  of  a  sick 
patient,  and  such  responsibility  as  observation  of  symp- 
toms or  the  carrying  out  of  more  difficult  treatment  is 
always,  in  ward  work,  shared  by  those  over  her.  Nothing 
will  deepen  the  sense  of  responsibility,  quicken  the  powers 
of  observation,  resource,  and  helpfulness,  or  put  an  end 
to  a  frivolous  or  flippant  attitude  toward  the  work  like 
contact  with  acute  illness  early  in  the  training. 

If,  however,  the  duties  are  otherwise  arranged,  a  point 
must  be  made  that  the  junior  nurses  help  the  seniors  with 
the  acute  cases. 

Dusting  and  Cleaning. — The  daily  dusting  and  cleaning  of 
a  ward  ought  certainly  to  be  divided  between  all  the  nurses, 


808       THE   HEAD   NURSE    AND   WARD   MANAGEMENT 

for  the  reason  already  stated.  Usually  the  work  can  be 
grouped,  as,  for  example,  one  side  of  the  ward  with  certain 
tables,  dressing-stands,  etc. ;  the  other  side,  with  bath-room, 
corridor,  or  equivalent;  the  service-room  and  lavatories, 
and  so  forth,  according  to  the  hospital  construction.  It 
matters  little  how,  if  the  adjustment  is  fair,  and  if  each 
nurse  knows  exactly  what  her  own  work  is.  In  this 
respect  the  senior  nurse's  duties  may  be  lighter  than  the 
others,  since  she  will  probably  have  certain  other  duties 
which  cannot  be  shared. 

In  the  same  way  the  closets,  drawers,  and  supply-boxes 
should  also  be  divided  between  the  nurses,  and  each  held 
responsible  for  keeping  her  share  in  perfect  order  and  fully 
supplied.  Thus  the  medicine  cupboard  would  be  in  charge 
of  one,  the  surgical  supply  closet  of  another,  the  clothes- 
closet,  linen-closet,  milk-chest,  refrigerator,  and  china 
closet  all  divided  out.  Besides  the  daily  care,  it  should  be 
a  rule  that  each  closet,  etc.,  be  thoroughly  cleaned,  over- 
looked, and  the  supplies  brought  up-to-date  once  a  week 
regularly.  If  such  work  is  left  merely  to  the  convenient 
moment,  it  is  never  done. 

Duties  that  may  be  interchangeable  are,  for  example,  the 
giving  of  the  regular  medicines;  the  preparing  and  dis- 
tributing of  lunches  and  extra  nourishment;  minor  dress- 
ings, fomentations  and  poultices;  the  taking  of  the  regular 
temperatures;  the  counting  of  soiled  clothes  for  the  laundry, 
and  distribution  of  daily  clean  towels,  etc.  These  duties 
may  often,  with  advantage,  be  taken  by  the  nurses  in 
turn  for  a  week  at  a  time,  a  regular  order  of  rotation  being 
maintained.  There  must,  however,  never  be  any  doubt 
as  to  who  is  responsible  for  each  duty. 

A  rule  that  admits  of  no  exception  should  be  that  each 
nurse  cleans  whatever  she  herself  has  used,  and  returns  it 
to  its  place  as  soon  as  it  is  done  with.  The  habit  of  making 
younger  nurses  fetch  and  carry  and  clean  up  for  the  older 
ones  may  be  good  discipline  for  the  junior,  but  is  altogether 
wrong  from  any  other  point  of  view.  If  any  one  requires 
special  help,  it  is  the  less  experienced  junior. 

The  night  nurse,  although  exempt  from  the  work  of 
meals  and  the  busy  rush  of  the  doctor's  visits,  still,  if  the 


THE    WARD-MAID  809 

patients  are  sick,  has  her  hands  too  full  to  give  much  time  to 
the  domestic  ward  work,  nor  can  she  be  given  duties  that 
keep  her  out  of  the  wards,  even  in  the  diet  kitchen  or  ser- 
vice-room. There  are  periods,  however,  especially  in  sur- 
gical wards,  where  there  may  be  a  considerable  amount 
of  idle  time  while  the  patients  sleep.  It  is  always  best 
to  leave  definite  work  for  these  hours,  otherwise  novels, 
letters,  or  fancy  work  will  creep  in  and  open  the  way  for 
wasting  time  that  belongs  to  the  patient. 

If  the  hours  on  duty  of  the  night  nurse  overlap  those  of 
the  day  nurse,  it  is  usual  to  give  some  special  duties  for 
this  time,  since  she  is  no  longer  wanted  exclusively  in  the 
wards,  such,  for  example,  as  counting  out  the  laundry, 
cleansing  and  disinfecting  the  lavatory  crockery.  With 
more  common-sensible  ideas,  however,  on  the  uselessness 
of  unnecessarily  prolonging  hours  of  duty,  the  hours  of  a 
night  nurse  are  generally  curtailed  as  much  as  possible. 

THE  ORDERLY 

In  a  male  ward  the  orderly  has  very  definite  duties.  He 
gives  the  baths  to  all  except  the  very  sick,  attends  to  bed- 
pans and  urinals,  enemas,  and  similar  treatment,  assists 
the  doctors  with  the  screen  cases,  and  helps  in  other  minor 
duties,  such  as  feeding  helpless  cases,  and  so  forth.  Usu- 
ally the  domestic  work  given  to  him  is  the  care  of  the 
lavatory  crockery,  including  the  spittoons,  and  the  polish- 
ing of  the  ward  "  brights,"  such  as  taps,  gas-brackets, 
etc.  Where  his  duties  are  light,  some  general  cleaning 
is  often  given,  too — window  cleaning,  for  example,  or 
cleaning  walls.  When  it  can  be  avoided,  however,  the 
orderlies  will  generally  be  found  to  give  more  satisfactory 
work  if  they  are  kept  to  duties  that  immediately  concern 
the  patients. 

THE  WARD-MAID 

Next  to  a  good  head  nurse,  a  good  ward-maid  is  probably 
the  most  important  item  for  the  general  comfort  of  a  ward. 
Her  duties  vary  considerably  in  different  hospitals.  In 
some  she  is  merely  the  scrubber,  occupied  entirely  with 
floors,  grates,  where  such  exist,  and  washing  up  dishes;  in 
others,  besides  these  duties,  she  sets  the  trays  for  meals, 


810       THE   HEAD   NURSE   AND   WARD   MANAGEMENT 


helps  in  serving  them,  and  does  a  fair  share  of  the  ward 
dusting  and  cleaning.  I  think  most  experienced  nurses 
will  agree  it  is  a  mistake  to  have  her  do  even  minor  duties 
about  the  patients.  Whatever  her  duties,  they  should  be 
well  defined,  and  the  daily  duties  performed  always  in 
the  same  order,  and  as  nearly  as  possible  at  the  same  time, 
the  weekly  cleaning  in  a  certain  order  of  rotation. 

It  is  a  good  system  to  have  the  ward-maids'  duties 
written  down  and  hung  where  they  can  be  readily  referred 
to.  At  the  same  time,  it  is  better  to  avoid  needless  de- 
tails or  a  schedule  written  out  with  fresh  duties  opposite 
every  half-hour.  You  will  find  these  long  and  minute 
schedules  are  never  read  and  rarely  referred  to.  A 
schedule  prepared  in  the  following  order  is  generally  prac- 
tical : 

Ward-maid  —  Ward  A. 


(  Breakfast 
-j  Dinner 
(  Supper 


Hours  of  meals: 

Hours  of  duty: 

f  Breakfast 

Hours  of  patients  meals:]  Dinner 
(.  Supper 

Daily  Work. 

Before  breakfast:  Set  breakfast  trays;  prepare  and  help 

to  serve  patients'  breakfast. 
f  Wash  breakfast  things,  sweep  wards, 


A  specified  hour: 
A  specified  hour: 

After  dinner: 


Before  supper: 
After  supper: 


in  the  order  in  which  it  is  most  con- 

veniently  performed). 
Begin  weekly  cleaning. 
Set  patients'  dinner  trays,  etc.  (enum- 

erate the  special  duties  entailed). 
Wash  patients'  dinner  things.     Tidy 

kitchen,    etc.      Finish    the    weekly 

cleaning  before  the  time  off  duty. 
Set  patients'  supper  trays,  etc. 
Wash  patients'  supper  things.     Tidy 

the  kitchen,  etc. 


Weekly  Cleaning. 

Monday:        Scrub  ......  Thursday:  Scrub  ...... 

Tuesday:       Scrub  ......  Friday:       Scrub  ...... 

Wednesday:  Clean  closets,  etc.  Saturday:    Sweep  walls.    Clean 
Turn  out  china  closet.  knives  and  spoons,  etc. 


HOURS  OFF  DUTY  811 

It  is  human  nature  to  work  better  if  we  feel  a  certain 
responsibility  and  possession  in  our  work,  and  it  is  time 
well  spent  to  stimulate  this  feeling  in  our  ward-maid. 
Give  her  also  some  one  thing  in  which  she  can  take  a  special 
pride;  for  example,  give  her  the  charge  of  the  china-closet, 
and  take  time  yourself  to  go  over  a  working  inventory  of 
its  contents  with  her  on  specified  dates.  You  will  hardly 
find  one  who  will  not  respond  to  this  treatment,  and  do  all 
her  work  better  for  the  little  personal  notice  this  entails. 

HOURS  OFF  DUTY 

The  length  of  the  hours  on  duty  is  not  determined  by 
the  ward  head  nurse,  but  with  her  usually  rests  the  arrange- 
ment of  the  hours  of  the  specified  time  off  duty.  In  the 
hands  of  a  good  organizer  the  practice  acts  well,  but  we 
have  all  realized  its  shortcomings  in  the  hands  of  a  woman 
incapable  of  looking  forward  beyond  the  immediate  needs 
of  the  hour. 

In  hospitals  for  private  patients,  where  the  doctors 
change  constantly  and  their  visiting  hours  with  them,  and 
in  similar  conditions,  the  nurse's  time-table  may  require 
readjusting  daily,  but  there  seems  to  the  writer  little  excuse 
in  the  general  wards  of  general  hospitals  for  not  preparing 
a  schedule  of  time  off  duty  that  will  be  practical  at  least 
from  week  to  week.  We  are  never  tired  preaching  to  our 
pupils  the  uses  of  recreation  and  the  value  of  keeping  up 
their  outside  interests,  but  we  make  it  very  difficult  for 
them  to  do  so  if  they  can  make  no  engagement  even  a  day 
ahead,  and  feel  secure  they  can  keep  it. 

As  a  matter  of  fact,  we  can  foresee  the  work  much  more 
than  we  think.  Certain  events,  such  as  the  meals  and  all 
the  details  of  routine  work,  occur  at  the  same  hour  every 
day.  In  a  medical  ward  there  are  certain  hours  in  which 
the  pressure  of  work  will  be  greatest,  such  as  the  hours  in 
which  temperature,  baths,  packs,  or  sponges  are  prescribed, 
and  other  quieter  hours,  in  which  the  work  usually  will  not 
be  beyond  the  attainments  of  a  junior  nurse,  while,  espec- 
ially in  a  teaching  school,  the  hour  at  which  the  visiting 
doctor  arrives  with  his  students  is  generally  known  and 
fixed.  In  a  surgical  ward  the  hours  for  dressings,  the  sur- 


812      THE  HEAD   NURSE   AND   WARD   MANAGEMENT 

geon's  visit,  even  the  operating  days  and  hours,  are  prac- 
tically unchanged  year  in  and  year  out.  Is  it  not,  then,  quite 
practical  to  decide  at  what  hour,  you  are  most  likely  to  be 
sure  to  require  your  senior  nurse  or  to  be  able  to  manage 
with  the  juniors?  To  know  definitely  when  she  is  to  be 
"  off  "  and  when  "  on  "  is  a  real  source  of  contentment  and 
pleasure  to  a  pupil,  and  should  not  be  denied  merely  for 
want  of  the  will  to  take  some  pains  in  the  matter  and  look 
sufficiently  far  ahead.  The  hours  may  then  be  printed  or 
written  up  in  some  convenient  place  for  ready  reference, 
thus : 


Mon. 

Tues. 

Wed. 

Thurs. 

Fri. 

Sat. 

Senior  

Second  nurse  .  .  . 
Third  nurse  .... 
Probationer,  etc. 

with  some  simply  worded  notice  that  sudden  emergencies 
and  other  special  conditions  may  call  for  a  temporary  re- 
arrangement of  the  hours.  The  Sunday  hours  are  usually 
arranged  specially,  that  each  nurse  may  have  a  larger 
portion  of  the  day  to  herself  and  sufficient  time  to  attend 
her  own  church.  The  specified  hours  may  be  taken  in 
rotation,  so  that  each  may  know  beforehand  what  time  she 
can  count  upon. 

Punctuality,  both  in  leaving  the  wards  and  in  returning  to 
duty,  should  be  exacted.  At  the  same  time  our  patients 
are  considerably  more  than  our  mere  duty,  and  any  service 
begun  for  a  patient  should,  as  a  rule,  be  finished  by  the 
same  nurse,  to  avoid  the  changes  so  trying  to  the  average 
patient.  The  habit  of  consideration  for  the  patient's 
feelings  cannot  be  too  strongly  insisted  upon  as  the  most 
important  point  of  view,  in  spite  of  conflicting  interests. 


REPORTING 

As  a  matter  of  routine,  every  nurse  on  going  off  duty 
or  on  returning  should  report  verbally  to  her  head  nurse 
or  to  the  nurse  taking  the  head  nurse's  place.  This  habit 


REPORTING  813 

keeps  the  head  nurse  in  touch  with  the  individual  worker, 
gives  an  opportunity  for  communicating  facts,  orders,  etc., 
which  might  otherwise  be  overlooked,  and  insures  punc- 
tuality. 

At  the  same  time,  every  detail  in  the  treatment  of  a 
patient  should  be  written  down  in  a  form  that  can  be  read- 
ily available  for  quick  reference.  The  system  of  report- 
ing can  be  so  complicated  as  greatly  to  increase  the  day's 
labor;  the  aim  should  be  to  supply  accurate  information 
in  the  simplest  manner  possible. 

Report  Book. — A  system  of  report  books,  one  for  day 
duty  and  one  for  night,  arranged  after  the  following  ex- 
ample, has  been  found  practical  and  convenient : 

Example:  JOHN  JONES. 

Temperature,  pulse,  respiration 8 — 12 — 4—8 

Milk,  5  ounces;  Vichy,  2  ounces 10 —  1 — 4 — 7 

Water,  5  ounces 9—12—3  —6 

Medicine 10—2—6 

Whisky,  2  drams 9—12—3—6 

Sponge  at  70°  F.  for  twenty  minutes  for 

temperature  over  102.4°  F 8—12—4—8 

Where  the  card  system  for  giving  medicine  is  used  (p. 
352),  it  will  not  be  necessary  to  write  down  the  medicine. 

As  each  detail  of  the  treatment  is  carried  out  a  pencil 
mark  is  crossed  through  the  hour.  At  a  glance,  then,  the 
nurse  in  charge  can  ascertain  what  treatment  has  been 
done  and  what  omitted.  If  purposely  omitted  as  not 
necessary,  or  for  some  other  reason,  a  circle  may  be  drawn 
round  the  hour  or  some  similar  distinctive  mark  made. 

For  example: 

Sponge  at  102.4°  F.,  etc.  &  y 

A  mark  without  either  cross  or  circle  would  indicate 
that  the  treatment  had  been  forgotten. 

Such  a  book  is  both  order  and  report  book.  Its  dis- 
advantage lies  in  the  considerable  amount  of  writing 
entailed  morning  and  evening.  This  may  be  mitigated  by 
using  copy-books  with  the  sheet  a  convenient  size  to  be 
ruled  off  into  several  spaces,  each  representing  a  day. 
Where  no  changes  in  the  orders  have  been  made,  the  space 
will  merely  indicate  "  as  before,"  the  hours  alone  requiring 


814   THE  HEAD  NURSE  AND  WARD  MANAGEMENT 

to  be  written  again.  The  writing  of  the  orders  should  be 
the  duty  of  the  head  nurse. 

The  doctor's  orders,  from  which  the  above  reports  are 
compiled,  should,  without  any  exception,  be  in  writing,  and 
no  change  in  treatment  should  be  permitted  except  on 
receipt  of  a  written  order.  The  doctor's  orders,  including 
diet,  direction  for  treatment,  and  medical  prescriptions, 
are  in  some  hospitals  entered  directly  in  a  ward  day-book; 
in  others,  on  'bed-boards  or  prescription  sheets  hung  over 
the  patient's  bed,  side  by  side  with  his  temperature  chart 
and  his  history  notes.  Either  practice  has  its  advantages 
and  some  drawbacks.  It  may,  for  example,  frequently  be 
a  disadvantage  for  a  patient  or  his  friends  to  have  such 
easy  access  to  all  information  concerning  his  treatment. 
If  the  bed-board  system  is  used,  it  is  a  rule  that,  as  soon  as 
an  order  is  written,  the  board  is  laid  on  the.  table  until  the 
order  has  been  entered  in  the  "  report  "  book. 

The  temperatures,  pulse,  and  respirations,  together  with 
the  record  of  the  excreta,  are  entered  in  a  separate  copy- 
book from  which  the  temperature  charts  are  compiled. 
Unusual  symptoms,  such  as  rigors,  vomiting,  etc.,  must 
obviously  be  reported  instantly  to  the  head  nurse,  and  by 
her  to  the  doctor,  but  as  a  further  safeguard  against  over- 
sight the  fact  and  the  hour  of  occurrence  should  be  noted 
on  a  slip  of  paper  and  placed  on  a  file  on  the  record 
table. 

The  night  report  should  be  reinforced  by  a  written  sum- 
mary from  the  night  nurse  with  reference  to  the  sleep, 
special  symptoms,  fresh  orders,  and  treatment  of  the 
patients  under  her  charge  during  the  night. 

Verbal  reports  are  also  important,  especially  as  a  training 
to  the  pupils  for  their  future  work.  It  is  not  really  an  easy 
thing  for  the  average  nurse  to  collect  her  thoughts  at  a 
moment's  notice  and  remember  all  necessary  facts  about 
an  individual  patient,  or  many  patients,  and  few  without 
practice  have  the  faculty  of  stating  the  facts  accurately 
and  briefly  without  the  help  of  leading  questions.  And 
yet,  either  as  head  nurses  or  in  private  work,  such  reporting 
is  constantly  required  of  them.  The  pupils  should  be 
taught  a  certain  routine  form,  beginning  with  routine  facts, 


REPORTING  815 

such  as  temperature,  record  of  excreta,  sleep,  appetite, 
etc.,  and  finish  with  abnormal  symptoms.  As  a  rule,  such 
a  report  should  be  received  from  each  day  nurse  before 
finally  leaving  the  ward  for  the  night,  and  from  the 
night  nurse  when  she  has  finished  her  work  in  the  morning. 
After  receiving  the  night  nurse's  report  and  reading  the 
order  book,  etc.,  the  head  nurse  should  call  the  day  nurses 
together  and  go  briefly  over  the  changes  in  the  order  of 
treatment  and  the  report  of  special  symptoms,  etc.,  that 
have  occurred  during  the  night. 

It  may  be  pertinent  to  add  that  there  is  often  a  tendency 
to  allow  reporting  to  degenerate  into  gossiping  or  chatter 
on  irrelevant  subjects.  Young  head  nurses  in  particular 
should  be  careful  to  guard  against  such  a  habit.  Insist 
always  that  all  reports  are  given  in  a  business-like  attitude, 
and  in  concise,  business-like  terms,  the  reporting  nurse 
standing  upright,  her  hands  crossed  in  front  of  her,  in  an 
attitude  of  drill.  Nurses  giving  their  reports  either  lolling 
over  the  table  or  standing,  their  hands  easily  on  their 
hips,  is  not  a  matter  that  actually  affects  the  well-being  of 
the  patient,  but  certainly  suggests  a  lack  of  finish  in  the 
training  that  will  probably  also  have  other  more  import- 
ant manifestations. 

Charts. — From  the  above  "  reports  "  the  daily  records 
are  compiled  in  the  form  of  charts,  some  of  which  form  a  per- 
manent part  of  the  patient's  history,  and  all  of  which  are 
preserved  for  reference  during  the  whole  course  of  the 
patient's  illness  (Chap.  V). 

A  special  sheet  should  also  be  kept  recording  the  diet 
of  each  patient,  for  quick  reference  at  the  serving  of  meals. 

Diet-sheets. — In  all  hospitals  the  different  diets  are 
classified  under  such  headings  as  liquid  diet,  house  diet, 
extra  diet,  etc.  (p.  782).  A  printed  table  is  generally 
kept,  with  a  list  of  the  items  included  under  such  headings. 
Extras  are  ordered  by  item,  such  as  oysters,  fruit,  game, 
beef-juice,  extra  eggs,  or  milk,  etc. 

The  diet-sheets  should  give  the  names  of  the  patients 
under  the  different  diets,  and  be  corrected  from  day  to 
day. 


816       THE   HEAD  NURSE   AND    WARD   MANAGEMENT 

STOCK-BOOKS  AND  INVENTORIES 

Stock-books. — The  care  of  the  equipment  is  again  one  of 
the  important  responsibilities  of  a  head  nurse.  Left 
entirely  to  such  casual  care  as  the  individual  worker  may 
think  of  bestowing,  we  have  invariably,  as  the  result,  a 
spectacle  of  loss,  waste,  and  destruction  of  property  that 
positively  seems  wanton,  and  accounts,  year  by  year,  for 
considerable  sums  of  money  that  would  otherwise  be  avail- 
able for  other  purposes.  To  guard  against  such  a  condi- 
tion, a  system  of  methodical  and  scrupulously  honest  stock- 
keeping,  coupled  with  persevering  and  constant  vigilance, 
is  necessary.  The  former  should  not  be  left  to  the  initia- 
tive of  young  head  nurses.  A  good  and  simple  system 
should  be  thought  out  by  the  hospital  authorities,  and 
carried  on  in  every  department  with  similar  care,  whether 
wards,  operating-rooms,  laundry,  kitchens,  library,  or  any 
other  department. 

Every  article  given  to  a  ward  (since  we  are  at  present 
discussing  ward  work),  from  the  weekly  allowance  of  soap 
or  safety-pins  to  bed-linen,  surgical  instruments,  or  new 
furniture,  should  be  entered  in  writing.  This  may  be 
done  elaborately  by  a  system  of  card  cataloging,  always 
in  the  long  run  a  convenience,  or  more  simply  by  keeping 
a  set  of  requisition  books  and  checking  carefully  the  articles 
received.  For  example,  one  book  would  be  reserved  for 
household  supplies,  another  for  ward  crockery,  a  third  for 
linen  and  ward  furnishing,  and  a  fourth  for  surgical  instru- 
ments and  supplies.  These  books  are  thus  in  the  nature  of 
receipts,  and  should,  therefore,  not  be  destroyed  when 
complete  until  a  given  time  has  elapsed. 

This,  however,  constitutes  but  the  first  step  in  the  neces- 
sary care.  The  next  is  to  minimize  the  risk  of  loss.  The 
best  way  yet  devised  is  to  take  regular,  and,  one  may  add, 
honest,  inventories.  How  often  the  inventories  should  be 
taken  may  be  a  matter  of  opinion,  obviously,  the  more 
frequently  they  are  done,  the  more  easily  will  they  be 
accomplished. 

Inventories. — The  inventory  for  the  ward  china,  glass, 
knives,  and  spoons,  etc.,  may  be  conveniently  kept  in  the 
form  of  a  sheet  or  card  ruled  into  weeks  and  fastened  up 


STOCK-BOOKS   AND    INVENTORIES 


817 


inside  the  china-closet.  The  complete  number  of  articles 
in  stock  should  be  entered  at  the  beginning  of  the  list, 
and  a  regular  day  set  aside  for  the  counting.  It  is  a  good 
rule  to  do  the  counting  each  week  on  the  day  on  which  the 
china-closet  is  scrubbed,  and  an  excellent  plan  to  do  it  with 
the  ward-maid.  She  soon  comes  to  feel  responsible  for 
not  allowing  the  articles  to  stray,  and  after  a  few  weeks 
of  encouragement  on  the  subject  will  invariably  take  a 
pride  in  keeping  her  things  together. 

FORM   OF  INVENTORY 


30  cups  

FEBRUARY. 

7 

14 

21 

28 

30 
30 
60 
30 
60 
30 
30 

30  saucers  

60  plates  

30  glasses  

60  spoons  

30  knives  .  . 

30  forks,  etc. 

The  same  form  of  inventory  may  ke  kept  for  surgical 
instruments  and  supplies,  for  lavatory  supplies,  including 
bed-pans,  urinals,  sputum-cups,  rectal  tubes,  catheters, 
douche-cans,  etc.,  and  for  medical  supplies,  including  pneu- 
monia jackets,  stupe  flannels,  poultice  binders,  and  so  forth. 
These  inventories  are  usually  most  conveniently  kept  in 
small  separate  copy-books.  They  also  should  be  taken  at 
regular  and  frequent  intervals — once  a  week  is  not  too 
often — and  gone  over  personally  with  the  nurse  in  whose 
charge  they  for  the  time  are.  When  these  duties  are 
changed,  the  inventory  should  be  again  carefully  checked, 
that  the  nurse  taking  up  the  duty  may  know  exactly  what 
she  is  responsible  for. 

The  furniture  inventory  (beds,  mattresses,  lockers,  etc.) 
is  frequently  not  left  in  the  charge  of  the  head  nurse,  but 
kept  and  taken  from  time  to  time  by  the  hospital  author- 
ities. 

The  linen  inventory  is  perhaps  the  most  important  of  all, 
since,  of  all  ward  equipment,  this  alone  leaves  the  ward 

52 


818       THE   HEAD    NURSE    AND   WARD   MANAGEMENT 

and  is  handled,  both  for  washing  and  for  repair,  by  persons 
outside  the  ward.  As  the  linen  represents  a  very  large 
item  of  expenditure,  it  should  be  closely  looked  after. 
Besides  the  regular  inventory,  the  care  of  the  linen  entails 
a  carefully  kept  laundry  book  and  a  repair  book. 

Printed  laundry  books  with  duplicate  slips  which  are  sent 
to  the  laundry  with  the  soiled  clothes  are  usually  provided. 
From  the  duplicate  slips  the  clothes  can  be  rechecked  in 
the  laundry,  and  by  comparing  the  return  laundry  with 
the  list  in  the  book,  losses  can,  to  some  extent,  be  at  once 
detected.  Where  the  laundry  sorting-room  is  well  organ- 
ized, linen  for  repair  is  usually  sent  straight  from  the  sort- 
ing-room to  the  linen-room;  in  other  cases  it  should  be  a 
special  duty  of  one  or  other  of  the  nurses  to  sort  out  the 
clean  linen  and  set  on  one  side  all  that  require  repair. 
In  either  case  the  articles  should  be  enumerated  in  a  book 
kept  for  the  purpose,  which  may  conveniently  be  arranged 
as  follows: 

Example: 


Items. 

Received. 

Returned. 

Condemned. 

3  sheets 

March  8th 

2,  March  12th 

1 

All  condemned  articles  are  replaced  by  new  ones  either 
immediately  or,  more  conveniently,  on  a  certain  day,  say, 
once  a  month,  thus  keeping  up  the  full  supply  of  linen. 

The  linen  inventories  have  a  more  official  appearance, 
and  are  generally  more  carefully  kept,  if  printed  forms  are 
used  in  place  of  the  ruled  copy-books,  which  are  quite  suffi- 
cient for  china  lists  and  surgical  supplies,  etc.  They  can 
be  bound  inexpensively  in  the  form  of  small  books.  The 
first  page  should  state  the  standard  number  of  the  different 
articles  required.  Some  losses  are  almost  certain  to  take 
place  from  month  to  month,  at  least  until  the  inventory 
system  is  well  established,  -and  the  full  amount  will  from 
time  to  time,  perhaps  twice  a  year,  require  to  be  made  up. 


STOCK-BOOKS   AND    INVENTORIES 


819 


A  practical  linen  inventory  may  be  arranged  in  the 
following  manner: 

Ward.  No.  of  Beds 

Date  . . 


Number  pre- 
ceding 
month. 

Items. 

Con- 
demned. 

New. 

Unac- 
counted 
for. 

Total. 

Number 
per  bed. 

Signed Head  Nurse. 

New  articles  are  given  only  in  place  of  those  condemned. 
"  Unaccounted  for  "  may  indicate  actual  loss  or  merely 
that  the  articles  have  strayed  to  another  department,  to 
be  recovered  subsequently.  One  of  the  most  satisfactory 
results  in  keeping  careful  inventories  is  observed  in  the 
steady  decrease  in  the  numbers  under  this  heading  as 
the  practice  of  taking  the  inventory  becomes  confirmed. 
By  placing  on  the  left  of  the  list  the  number  of  the  pre- 
ceding month  (or  last  inventory),  and  not  the  standard 
numbers,  the  date  of  any  loss  is  clearly  shown. 

The  amount  of  linen  required  by  a  ward  depends  on  the 
activity  of  its  service  and  its  laundry  facilities.  Thus, 
if  the  linen  sent  down  daily  is  returned  on  the  following 
day,  a  smaller  amount  will  be  necessary  than  if  the  linen 
is  returned  from  the  laundry  only  twice  or  three  times  a 
week.  The  following  list  includes  the  average  amount 
per  bed  usually  considered  necessary: 

Sheets 6  to  10  per  bed. 

Draw-sheets 4  to    6 

Pillow-cases 6  to  10 

Blankets 2  to    3 

Spreads 1?  to    2 

Patients'  towels 4  to    6 

Diet  towels 4  to    6 

Roller  towels 12  to  24 

Hand  towels  for  doctors 36  to  72 

Dish-towels,    and    all    other    small 

towels,  etc.,  of  each 6  to  12 


820       THE  HP] AD  NURSE   AND   WARD   MANAGEMENT 

If  night-shirts  are  provided,  the  supply  can  hardly  be 
too  generous;  in  many  hospitals,  however,  the  patients 
supply  their  own  shirts,  a  certain  number  especially  made 
for  bed  cases  only  being  supplied  by  the  hospital. 

CARE  OF  LINEN 

The  care  of  the  linen  is,  however,  only  begun  with  the 
taking  of  the  inventory,  and  a  head  nurse  will  find  herself 
obliged  to  exercise  constant  vigilance  in  its  use. 

Insist,  in  the  first  place,  that  linen  is  used  only  for  the 
purpose  for  which  each  piece  is  provided,  otherwise  pillow- 
cases will  serve  for  sand-bag  covers,  crumpled  sheets  for 
draw-sheets,  and  all  small  towels  for  dusters,  all  of  which 
implies  an  increase  of  wear  and  tear  on  an  unnecessarily 
good  class  of  material.  Stains  which  result  from  careless- 
ness or  inevitably  from  the  kind  of  work  should  be  treated 
as  soon  as  they  occur,  and  before,  if  possible,  they  have 
time  to  dry. 

Blood-stains  should  be  soaked  in  cold  water,  and  not 
allowed  to  dry  before  they  are  washed.  They  should  be 
washed  with  Ivory  soap  in  cold  water.  Small  stains  on 
mattresses  or  pillow-ticking  can  be  completely  effaced  with 
peroxid  of  hydrogen.  This,  however,  is  an  expensive 
method,  only  permissible  where  it  is  impractical  to  wash 
the  articles  in  question. 

Sheets  and  diapers  soiled  with  fecal  matter  should  be 
taken  at  once  to  the  lavatory  hopper  and  under  running 
cold  water  brushed  as  clean  as  possible  with  a  long-handled 
hard  brush.  The  custom  of  sending  badly  soiled  sheets 
or  infants'  diapers  to  the  laundry  without  such  treatment, 
to  wait  possibly  twenty-four  hours  before  they  are  washed, 
is  obviously  objectionable,  and  especially  so  in  hospital 
work. 

Ink-stains  should  not  be  exposed  to  light  or  treated  with 
hot  water,  since  either  will  blacken  the  nitrate  of  silver  all 
inks  contain. 

In  the  Boston  Cooking  School  Cook-book  Miss  Farmer 
recommends  washing  in  a  solution  of  hydrochloric  acid, 
rinsing  immediately  after  in  ammonia  water  (to  arrest 


CARK   OF   LINEN  821 

the  action  of  the  acid);  the  stain  is  then  wet  with  warm 
water,  rubbed  over  with  Sapolio,  and  gently  rubbed  be- 
tween the  hands.  Small  spots  may  be  covered  with  salt 
and  rubbed  with  a  piece  of  lemon. 

Stains  from  iron-rust  are  still  more  difficult  to  remove, 
but  may  yield  to  the  same  treatment  as  that  for  ink-stains. 
Whenever  an  acid  is  used  in  bleaching,  the  material  must 
be  rinsed  in  an  alkali  to  check  the  action  of  the  acid,  which 
will  otherwise  cause  holes. 

lodin  stains  are  treated  with  a  paste  of  starch  and  alcohol, 
or,  if  trifling,  by  sponging  with  ammonia  water  or  with 
alcohol. 

Tea  and  coffee  stains  are  easily  removed  if  washed  at 
once ;  if  there  is  milk  or  cream  in  the  stain,  it  must  first 
be  washed  in  cold  water. 

Fruit-stains,  especially  those  from  peaches  and  pears, 
are  very  intractable  and  are  indelible  if  the  linen  is  washed 
before  removal.  Hydrochloric  acid  or  oxalic  acid  may  be 
used  exactly  on  the  spot,  rinsing  immediately  in  ammonia 
water,  and  then  washing  with  Ivory  soap  and  cold  water. 

Stains  from  oil  or  grease  must  also  be  removed  before 
the  linen  is  washed.  Ether,  benzin,  or  gasoline  may  be  used. 
As  these  are  highly  inflammable,  care  must  be  taken  to 
keep  them  away  from  an  exposed  light.  When  the  stain 
is  small,  Ivory  soap  and  cold  water  may  be  sufficient  to 
remove  it. 

Bichlorid  of  mercury  turns  linen  an  ugly  gray  color 
after  it  is  exposed  to  the  heat  of  washing,  and  should, 
therefore,  not  be  used  for  disinfection.  If  stains  occur, 
they  may  be  removed  by  soaking  the  linen  in  a  cold  solution 
of  chlorinated  lime  and  carbonate  of  soda  (Labarraque's) 
for  several  hours.  They  must  then  be  at  once  rinsed  and 
washed,  as  the  soda  is  injurious  to  the  linen. 

Linen  torn  in  any  way  or  wanting  tapes  or  buttons  should 
l)e  set  aside  for  repair,  and  not,  as  is  too  often  the  case,  used 
again  and  again  until  a  small  tear  has  become  one  wanting 
several  hours'  work. 

Disinfection  of  Linen. — See  Disinfectants,  Chap.  XII. 


822      THE   HEAD   NURSE   AND   WARD   MANAGEMENT 

BLANKETS 

The  most  careful  washing  in  time  causes  blankets  to 
shrink  and  invariably  spoils  their  appearance.  With  the 
more  expensive  varieties,  such  as  provided  for  the  private 
rooms,  it  is  an  economy,  in  the  long  run,  to  send  them  to 
the  dry  cleaners  rather  than  wash  them.  From  the  dry 
cleaner  they  return  as  good  as  new,  and  with  reasonable 
care  will  last  many  years.  Nurses  should  take  a  pride  in 
keeping  their  blankets  clean.  Finger-marks  and  spots 
can  be  minimized  by  doubling  the  end  of  the  spread  over 
the  tops  of  the  blankets  before  turning  back  the  sheet. 
If  stains  occur,  they  should  be  sponged  aff  at  once  in  cold 
water,  after  which  place  the  portion  to  be  washed  over  a 
board,  and  with  a  piece  of  flannel  wash  off  the  spot  with 
a  lather  of  Ivory  soap  and  tepid  water;  rinse  only  partially, 
rub  with  a  dry  cloth,  and  finish  drying  in  the  air  and  sun. 

A  less  expensive  variety  of  blanket  is  more  practical  for 
use  in  the  general  wards.  Here,  besides  the  purpose  for 
which  blankets  are  originally  intended,  we  find  them  put 
to  various  uses:  soaked  in  boiling  hot  water  for  hot  packs; 
dampened  with  steam  from  the  sweat-bath,  wrapped  round 
a  patient  dripping  with  perspiration,  and  so  forth;  add  to 
which  the  nature  of  the  cases  compels  us  to  have  the  ward 
blankets  continually  in  the  wash-tub.  We  all  know  the 
forlorn  aspect  of  the  average  ward  blanket  after  it  has  been 
but  a  few  weeks  in  use — its  diminished  size,  the  curious 
frilled  appearance  caused  by  the  unequal  shrinking  of  its 
gay  borders,  the  lighter  weight,  the  harsh  feeling  of  the 
wool.  Except  in  using  for  their  original  purpose,  a  full- 
sized  blanket  is  an  un wieldly  article.  For  the  uses  just 
enumerated  old  blankets,  the  shrunk  margins  cut  off  and 
bound  with  strips  of  stout  muslin,  are  much  more  practical, 
and  if  provided,  their  use  should  be  rigorously  insisted  on. 
Unless  the  old  blankets  are  adapted  in  some  such  way,  there 
will  always  be  a  difference  of  opinion  as  to  which  blanket 
is  old  and  risk  of  a  good  one  being  spoilt.  Some  hospitals 
provide  crib  blankets  of  a  light  weight,  made  without 
margins  for  all  extraneous  uses — a  plan  that  certainly  con- 
tributes to  the  longer  life  of  the  more  expensive  article. 

In  washing,  tepid  water  and  white  soap  without  soda 


PATIENTS'  EFFECTS  823 

are  used.  After  washing  and  rinsing,  a  bucket  of  tepid 
suds  should  be  thrown  over  the  blankets  and  only  partially 
wrung  out.  The  soap  helps  to  keep  the  blanket  soft  and 
replaces,  to  some  extent,  the  natural  oil  of  the  wool  lost  in 
frequent  washing. 

With  the  first  hot  weather  all  spare  blankets  should  be 
put  up  in  moth-balls,  and  moth-balls  also  laid  between  the 
fold  of  those  left  on  the  shelves.  Where  special  chests 
or  closets  are  not  provided,  the  blankets,  well  packed  with 
moth-balls,  may  be  wrapped  in  several  thicknesses  of 
newspaper.  Moths  apparently  dislike  printers'  ink,  and 
newspaper  wrappings,  it  is  found,  are  never  eaten  through, 
as  frequently  occurs  with  wrappings  of  cotton,  etc. 

PATIENTS'  EFFECTS 

The  personal  effects  of  patients  in  the  general  wards 
become  an  item  of  constant  trouble  unless  their  loss  is 
controlled  by  some  methodical  system. 

Wherever  possible,  the  clothes  should  be  returned  to  the 
friends,  since  clothes  that  have  been  worn  are  undesirable 
articles  to  pack  away  in  closets.  Frequently,  however,  this 
is  not  practicable.  In  these  cases,  as  soon  as  the  patient  is 
undressed  the  clothing  should  be  gone  over  and  the  items 
carefully  listed,  the  list  entered  in  a  book  kept  for  that  pur- 
pose and  signed  by  the  nurse  who  has  taken  the  list. 
The  clothing  is  then  made  into  a  bundle  and  clearly  marked 
with  the  patient's  name,  the  ward,  and  the  date  of  admis- 
sion. All  small  articles  in  the  pocket,  with  the  money, 
railway  tickets,  etc.,  should  be  made  into  a  separate  packet, 
also  carefully  listed,  preferably  in  a  separate  book,  and  kept 
under  lock  and  key  until  returned  to  the  patient.  For  these 
articles  a  receipt  is  usually  made  out  and  given  to  the 
patient,  and  it  should  be  a  rule  that  such  a  packet  is  opened 
only  by  the  patient  himself  or  in  his  presence. 
"  Should  it  be  necessary  to  send  any  personal  clothing  to 
the  hospital  laundry,  they  must  temporarily  be  marked 
with  the  name  of  the  ward,  otherwise,  being  unfamiliar 
to  the  laundry  staff,  they  may  easily  be  lost. 

Clothing  badly  infested  with  insects  is  best  burned. 
The  list  is  still  necessary,  however,  as  the  'equivalent  must 


824       THE   HEAD   NURSE   AND   WARD   MANAGEMENT 

be  given  to  the  patient  in  their  place.  If  this  is  impractical, 
they  should  be  first  fumigated  with  sulphur  to  destroy 
the  animal  life,  then  further  disinfected,  either  in  the  auto- 
clave or  by  subjection  to  live  steam  and  finally  washed. 
(See  Disinfection,  Chap.  XII.) 

SPECIAL  DUTIES  OF  A  HEAD  NURSE 

As  a  head  nurse  must,  in  her  daily  work,  meet  many 
conflicting  interests,  it  is  very  necessary  that  she  should 
arrange  her  various  duties  in  as  methodical  a  manner  as 
possible  in  order  to  give  to  each  the  necessary  time  and 
attention. 

Her  first  work  will  be  to  receive  the  report  of  the  night 
nurse  and,  following  that,  to.  interview  the  day  nurses  and 
see  that  they  understand  their  orders.  Next  in  order,  she 
should  make  a  point  of  seeing  and  speaking  to  each  patient 
under  her  care.  However  excellent  a  system  of  reporting, 
however  well  trained  and  disciplined  the  nurses  actually 
engaged  in  the  nursing  duties  may  be,  nothing  can  make 
up  for  a  lack  of  individual  interest  on  the  part  of  the  head 
nurse,  and  this  interest  must  be  shown  if  it  is  to  be  realized. 
It  would  seem  a  curious  point  to  insist  upon,  but  the 
writer  must  own  that  she  has  met  not  one  but  several 
head  nurses  who  did  almost  all  their  work  from  the  ward 
office.  They  were  certainly  fully  informed  as  to  all  that 
happened  in  their  ward,  but  they  literally  hardly  ever  saw 
a  patient  except  when  accompanying  the  doctors  in  their 
visiting  rounds,  unless  some  abnormal  condition  had 
been  reported.  One  felt  there  was  a  want  somewhere. 
Either  the  head  nurse  was  overoccupied  with  clerical  work, 
reports,  records,  and  so  forth,  so  that  actually  time  was 
wanting,  or  she  had  never  realized  the  privileges  of  her 
position. 

When  the  domestic  work  for  the  morning  is  finished, 
a  thorough  round  of  inspection  should  be  made  daily,  in- 
cluding closets,  lavatories,  milk-boxes,  refrigerator,  etc. 
The  work  of  the  ward-maid  and  orderlies  should  also  re- 
ceive methodical  inspection. 

Just  how  much  of  the  actual  nursing  it  is  best  for  a  head 


SPECIAL  DUTIES   OF  A   HEAD   NURSE  825 

nurse  to  do  it  is  impossible  to  say  on  general  principles; 
it  will  partly  be  determined  by  the  amount  of  work  to  be 
done,  the  nature  of  the  work,  and  the  powers  of  the  pupil 
nurses. 

A  head  nurse  is  a  captain,  not  a  soldier,  and  while  we  may 
at  times  feel  it  easier  to  do  a  piece  of  work  ourselves  than 
to  get  as  good  results  through  a  pupil,  this  is  weak  organ- 
ization, and  not  fair  to  the  pupil,  who  is  there  to  learn  her 
work.  At  the  same  time  nothing  is  worse  than  for  a  head 
nurse  to  cheapen  any  of  our  various  duties  by  taking  the 
attitude  that  some  are  beneath  her.  A  good  head  nurse 
should  do  everything,  from  dusting  upward,  just  a  little 
better  than  anyone  else  in  the  ward,  and  she  should  realize 
that  her  example,  whether  negative  or  positive,  is  bound  to 
have  its  influence  on  her  pupils. 

Whenever  possible,  the  head  nurse  should  superintend 
herself  the  serving  of  the  meals  and  ascertain  whether  they 
have  been  eaten  and  enjoyed  or  not.  In  her  absence  it 
should  be  the  work  of  the  senior  on  duty.  Meals  left  to 
the  junior  nurses  and  the  ward-maid,  while  the  senior's  diet 
duties  are  confined  to  administering  the  tonics,  although 
seemingly  illogical,  is  really  not  an  uncommon  division  of 
duties.  That  it  results  in  bad  service,  cold  food,  and  a 
general  attitude  of  indifference  toward  the  meals  is  not  an 
unnatural  sequence.  Any  deterioration  in  the  quality  or 
cooking  of  the  food  should  be  methodically  reported  in  the 
proper  quarter. 

In  some  hospitals  one  of  the  senior  nurses  is  put  in  charge 
of  the  diets,  her  duties  including  ordering  the  supplies, 
distributing  the  food,  and  superintending  the  service  of 
the  meals.  It  must  be  remembered,  however,  that  the 
nurse  is  only  learning  her  work,  and  that  training  will  be 
as  necessary  in  this  particular  as  in  any  other. 

All  the  various  details  of  nursing  duties  must,  if  they  are 
to  be  properly  done  as  regards  the  patient,  and  be  made 
of  full  value  in  the  nurse's  training,  be  subject  to  constant 
inspection  and  comment,  nor  should  the  head  nurse  ever 
feel  that  her  responsibilities  end  when  she  has  relegated 
the  duties  to  the  various  nurses.  To  the  last  day  of  her 
training  a  nurse's  duties  are  part  of  her  training,  and  it  is 


826      THE   HEAD  NURSE  AND   WARD  MANAGEMENT 

due  to  her  that  the  best  quality  of  work  should  be  taught 
and  exacted. 

In  going  off  duty  for  her  recreation  hour  the  head  nurse 
will  naturally  choose  the  time  in  which  there  are  likely  to 
be  least  demands  made  upon  her.  Wherever  possible  it 
ought  to  be  arranged  that  she  can  be  entirely  free  from  any 
calls  at  such  times.  In  her  absence  the  senior  nurse  takes 
her  place,  superintends  the  work  in  the  wards,  attends  any 
visiting  round,  takes  all  orders,  and  receives  any  new 
patients  that  may  be  admitted. 

THE  PATIENTS'  VISITORS 

One  weak  point  in  the  management  of  many  wards  is 
the  attitude  of  the  nursing  staff  toward  the  patients'  friends. 
They  forget  that  what  is  a  common  event  to  them  is  to 
these  people  an  unusual  experience,  and  they  are  naturally 
upset  and  anxious  and  often  a  little  aggressively  on  the 
watch  that  their  patient  should  not  be  defrauded  of  any 
of  his  rights.  To  treat  them  peremptorily,  or  even  in  a 
business-like,  unsympathetic  way,  only  confirms  their 
suspicions.  One  can  say  from  experience  that  most  hos- 
pitals where  good  nursing  standards  are  maintained  bear 
investigation,  and  the  more  these  methods  are  known,  the 
more  confidence  will  the  public  feel.  At  the  same  time 
this  confidence  cannot  be  taken  for  granted  and  is  easily 
destroyed  by  want  of  a  little  kindly  tact.  Nowhere  are 
good  manners  more  a  sheer  necessity  than  in  our  relation- 
ships with  the  public  in  just  these  circumstances,  and  to  err 
in  this  particular  is  a  serious  shortcoming,  however  sure 
we  may  be  that  as  soon  as  the  patient  is  left  in  our  charge 
we  shall  give  him  the  most  devoted  care.  Let  us  realize 
that  to  his  friends  this  is  not  a  foregone  conclusion. 

At  the  risk  of  sermonizing,  might  one  suggest  that  this 
is  specially  necessary  where  mothers  are  bringing  their 
children  to  hospitals.  We  do  not  realize  that  probably 
only  the  pressure  of  bitter  circumstances  induces  a  mother 
of  the  very  poor  classes  to  leave  her  child  in  a  place  that 
she  really  believes  to  be  a  place  of  torture  or,  at  best,  of 
unsympathetic  neglect.  Why  not  reassure  her  by  showing 
something  of  the  genuine  interest  and  pleasure  most  of 


DOMESTIC   WORK  827 

us  take  in  our  child  patients  ?  Let  her  realize  that  her 
child  is  among  friends,  and  she  will  go  away  with  one  bur- 
den less  on  her  heart.  And  in  her  weekly  visits  take  the 
trouble  to  talk  to  her  and  gain  her  confidence ;  it  is  quite  as 
easy  to  do  as  to  leave  her  to  gain  a  false  impression  if  you 
allow  her  to  feel  she  is  an  interloper  whose  visits  are  a 
trouble. 

To  take  the  other  side,  however,  in  our  "  visitors," 
especially  in  the  general  wards,  we  have  a  class  little  likely 
to  appreciate  the  wisdom  of  many  of  our  rules.  Unless 
close  watch  is  kept,  indigestible  food,  unwholesome  candy, 
and  alcoholic  drinks  will  certainly  be  smuggled  in.  It  is 
best  to  allow  a  list  of  wholesome  dainties,  fresh  eggs,  fresh 
fruit,  simple  cakes,  plain  ice-cream,  and  so  forth,  where 
the  patient's  condition  admits  of  such  food.  It  is  natural 
to  dislike  to  visit  a  patient  in  a  hospital  empty  handed, 
and  the  time  of  sickness  is  often  the  one  time  in  the  lives 
of  our  patients  that  they  may  allow  themselves  such  sim- 
ple luxuries. 

In  the  evening  the  head  nurse  should  again  visit  each 
patient  before  going  off  for  the  night  and  giving  over  the 
responsibility  of  the  ward  to  her  night  nurse.  However 
carefully  the  reports  are  made  out,  there  will  be  some 
individual  details  about  the  patients  to  be  mentioned. 
The  verbal  report  between  the  head  nurse  and  night  nurse 
should  always  be  regarded  as  an  important  part  of  the 
day's  routine.  Where  practical  it  is  always  a  good  thing 
for  the  head  nurse  to  see  the  night  superintendent.  In  a 
large  hospital,  however,  this  is  often  not  possible  without 
keeping  the  head  nurse  unnecessarily  long  on  duty. 

DOMESTIC  WORK 

The  routine  care  necessary  for  each  patient  has  been 
discussed  at  length  in  the  chapters  on  Practical  Methods. 

The  domestic  routine  care  will  require,  equally,  method  in 
its  management  and  punctuality  in  the  way  it  is  carried 
out.  A  ward,  where  dusting  is  done  here  and  there  all 
the  morning,  or  not  at  all  in  a  rush  of  work;  where  the 
baths  and  other  routine  details  are  fitted  in  anywhere,  is 
an  uncomfortable  one  for  the  patients  and  a  very  tiring 


828       THE  HEAD   NURSE   ANTD   WARD   MANAGEMENT 

one  for  the  nursing  staff.  There  should  be  an  hour  at 
which  the  domestic  work  should,  as  a  rule,  be  finished,  an 
hour  for  beginning  the  evening  work,  definite  time,  as  far  as 
possible,  for  all  the  routine  details.  Certain  work  that 
is  not  required  daily  should  have  its  special  day  for  being 
done. 

It  may  be  of  some  assistance  to  go  over  briefly  some 
accepted  methods  of  carrying  out  the  domestic  work  of  a 
ward. 

The  sweeping  of  polished  floors  must  be  done  with  a  hair 
broom.  After  the  dust  has  been  swept  up,  the  broom  may 
be  put  in  a  bag  of  washed  flannelette,  or  other  soft  material, 
and  the  floor  gone  over  thoroughly  with  a  regular  polishing 
movement.  For  scrubbed  wood  floor,  as  well  as  those  of 
stone  and  concrete,  the  ordinary  corn  broom  is  quite 
efficacious  and  more  economical.  Moistened  bran  or  used 
tea  leaves  well  washed  in  cold  water  may  be  used  with  ad- 
vantage as  dust  collectors,  and  prevent  the  dust  from  flying 
about.  From  time  to  time  brooms  should  be  washed  and 
thoroughly  dried  in  the  open  air.  When  not  in  use,  they 
should  be  hung  or  stood  within,  the  broom  end  uppermost. 

Mopping  is  not  a  good  substitute  for  scrubbing,  either 
for  stone  or  wooden  floors,  but  where  labor  is  inadequate, 
it  is  frequently  used  as  an  alternative.  The  water  must 
be  changed  frequently  or  the  floor  will  show  streaky  black 
marks.  Each  time  after  use  the  mop  should  be  washed  in 
hot  water  with  soda  or  soap  powder  and  dried  in  the  open 
air  before  being  put  away. 

Scrubbing  is  the  only  way  of  really  cleaning  stone  or 
woodwork.  The  secret  of  good  scrubbing  is  hard  rubbing, 
thorough  rinsing,  and  frequent  changing  of  the  water. 
Either  soft  soap,  a  good  scrubbing  soap,  or  soap  powder  in 
very  hot  water  serves  to  loosen  and  dissolve  the  dirt;  if 
not  carefully  rinsed  off,  however,  they  discolor  wooden 
floors,  turning  them  yellow  or  black. 

When  sand  can  be  procured,  it  forms  an  admirable  and 
inexpensive  means  of  cleaning  wooden  floors,  kitchen 
tables,  etc.  A  small  amount  of  soap  is  necessary  at  the 
same  time  if  the  wood  is  really  dirty.  The  sand  is  well 
sprinkled  on  the  boards  and  then  thoroughly  rubbed  into 


DOMESTIC   WORK  829 

the  grain  of  the  wood  with  a  hard  scrubbing-brush  and 
hot  water.  Unglazed  tiles,  whether  white  or  colored, 
should  be  scrubbed  with  a  good  sand-soap  and  plenty  of 
clean  hot  water,  and  will  require  to  be  scrubbed  daily  to 
present  a  good  appearance.  If  they  get  discolored  and 
streaky  from  the  soap,  they  may  be  gone  over  with  dilute 
muriatic  acid. 

Two  details  in  the  interest  of  economy  should  be  ob- 
served— first,  the  soap  must  not  be  left  standing  in  the 
water;  second,  scrubbing-brushes  and  floor  cloths  should 
invariably  be  washed  after  use,  well  rinsed,  and  thoroughly 
dried  before  being  put  away.  The  bucket  also  should 
be  rinsed  and  dried.  If  these  details  are  attended  to,  a 
housemaid's  closet  will  not  present  the  damp,  dirty,  dis- 
couraging appearance  so  commonly  seen,  but  will  look  as 
trim  and  neat  as  any  other  part  of  the  ward  equipment. 
Any  kneeling  work  may  cause  inflammation  of  the  bursa 
in  front  of  the  knee — what  is  known  as  housemaid's  knee. 
Kneelers  should,  therefore,  be  provided  with  a  suitable 
mat  or  an  old  blanket  folded  to  several  thicknesses  to  avert 
this  risk. 

Polishing. — Many  hospitals  now  have  polished  wooden 
floors  in  the  wards.  They  have  the  advantage  of  being 
less  absorbent  than  scrubbed  floors,  warmer,  and  less  tiring 
to  the  feet  than  any  form  of  stone  floor;  the  polished  surface 
is  also  considered  to  make  them  less  likely  to  harbor  germs. 
At  the  same  time,  they  require  a  considerable  amount  of 
time  spent  on  them  if  they  are  to  present  a  good  appear- 
ance, since  every  spill,  etc.,  spots  the  floor. 

Many  floor  polishes  are  on  the  market,  but  none  are 
better  than  a  mixture  of  beeswax  and  turpentine,  in  the 
proportion  of  one  part  beeswax  to  two  of  turpentine. 
The  beeswax  is  cut  up  in  small  lumps;  when  thoroughly 
dissolved,  it  forms  a  yellowish,  thick  fluid,  about  the  con- 
sistence of  cream.  A  very  small  amount  is  rubbed  directly 
on  the  floor,  a  few  yards  of  the  surface  at  a  time,  and  pol- 
ished until  perfectly  dry  with  a  special  weighted  brush  with 
a  long  handle.  The  brush  is  weighted  with  lead,  and  weighs 
about  thirty  pounds.  It  is  wrapped  in  a  piece  of  thick 
soft  flannel  or  blanket.  If  the  floor  is  left  sticky,  it  will 


830      THE   HEAD   NURSE   AND   WARD  MANAGEMENT 

catch  the  dirt  and  dust.  Any  such  accumulations  must 
be  removed  with  turpentine  before  repolishing  the  floor. 

In  many  hospitals  floors  are  colored,  varnished,  or  shel- 
lacked previous  to  polishing.  This  is  labor-saving  in  the  be- 
ginning, but  costly,  since  if  accidents  occur  which  remove 
the  polish, — and  they  are  almost  unavoidable, — there  is 
either  an  unsightly  patch,  or  the  whole  floor  must  be 
scraped  and  repolished.  Where  nothing  but  the  beeswax 
and  turpentine  mixture  is  used,  any  patch  can  be  quickly 
rubbed  up  to  look  like  the  rest  of  the  floor. 

The  weighted  polisher  must  be  used  daily,  and,  as  a  rule, 
once  a  week  is  sufficient  for  a  fresh  coating  of  polish. 

Only  hardwood  floors,  oak,  teak,  maple,  etc.,  are  capable 
of  taking  a  good  polish.  If  desired,  when  first  laid,  the 
boards  may  be  darkened  with  linseed  oil  before  polishing. 
At  first,  when  beeswax  and  turpentine  alone  are  used,  a 
considerable  amount  of  labor  is  necessary  before  the 
polished  boards  present  a  good  appearance;  once  well 
polished,  however,  they  are  easily  kept  at  comparatively 
small  cost. 

In  the  weekly  polishing  two  should  work  together — one 
kneeling  to  apply  the  polish,  and  the  other  using  the 
polisher.  With  a  little  practice  the  polisher  can  be  used 
without  much  exertion,  since  the  handle  is  on  a  hinge  and 
the  weighted  brush  can  be  pushed  backward  and  forward 
with  a  swinging  movement  not  difficult  to  acquire.  Floors 
covered  with  cork  carpet,  linoleum,  etc.,  may  either  be 
scrubbed  or  polished  in  the  same  way. 

Dusting  is  usually  the  first  of  the  domestic  duties  assigned 
to  the  nurses.  After  sweeping,  a  short  time  should  elapse 
to  allow  any  dust  that  has  been  raised  to  settle  before  the 
dusting  is  begun.  The  dusters  should  be  dampened  with 
clean  water,  in  order  that  the  dust  may  more  readily  adhere. 
The  use  of  a  disinfectant  is  an  unnecessary  expense,  since 
it  cannot  be  used  in  sufficient  strength  to  do  any  practical 
good.  For  polished  surfaces,  dry,  soft  dusters  should  be 
used. 

Dusting  must  be  taught,  so  slovenly  and  inadequate 
are  the  average  ideas  on  the  subject.  Every  corner  of 
the  ward,  including  any  ledges  above  the  level  of  the  head 


DOMESTIC  WORK  831 

and  the  top  of  the  skirting  boards,  should  be  thoroughly 
gone  over  daily.  At  the  present  day  ward  furniture  is 
especially  contrived  so  that  it  can  be  readily  cleaned,  a 
large  part  of  it  being  white  enamel  ironware  and  glass,  so 
that  there  is  no  excuse  for  anything  less  than  spotless  clean- 
liness. It  is  an  excellent  rule  that  each  nurse  should  wash 
out  her  own  duster  in  hot  soap  and  water  daily,  immediately 
after  use. 

Enamel  Ironware. — Finger-marks  and  most  stains  are 
easily  removed  by  washing  in  soap  and  water.  Soaps 
containing  pumice  or  sand  (Sapolio)  should  not  be  used, 
as  they  scratch  the  polished  surface  and  loosen  the  enamel. 
Acids  and  strong  disinfectants  also  destroy  the  polished 
surface.  Intractable  stains  are  best  removed  with 
Labarraque's  solution.  The  only  disadvantage  of  enameled 
iron  is  the  readiness  with  which  it  is  chipped — a  tendency 
that  is  apparently  increased  if  subjected  to  high  tempera- 
ture, as  in  the  autoclave.  Enameled  iron  is  the  popular 
ware  for  kitchenware  and  lavatory  utensils,  and  is  largely 
used  for  bath-tubs  and  sinks. 

Glass. — Soap  and  hot  water  are  quite  sufficient  to  clean 
glass,  and  the  use  of  expensive  drugs,  such  as  ammonia, 
alcohol,  liquor  potassa?,  etc.,  to  save  labor,  is  an  extrava- 
gant habit  that  should  never  be  countenanced.  Am- 
monia in  time  will  destroy  the  polished  surface  of  glass. 
Cheese-cloth  or  flannelette  rags  or  a  soft  chamois-skin 
should  be  used  to  rub  up  the  surface  after  washing.  Where 
glassware  has  become  badly  soiled  and  scrubbing  in  soap 
and  water  fails  to  remove  the  stains,  a  paste  of  whiting 
moistened  with  water,  if  the  stains  are  very  bad,  with  a 
little  ammonia,  may  be  used. 

Marble  becomes  discolored  with  ordinary  soaps  and 
stained  with  grease  and  many  of  the  commonly  used  dis- 
infectants. 

To  clean  marble  a  paste  of  whiting  and  ammonia  may 
be  made,  spread  over  the  surface,  and  left  overnight;  in 
the  morning  it  should  be  rubbed  away  with  a  dry  cloth. 
The  process  is  repeated  until  the  marble  is  clean. 

The  polish  of  marble  is  destroyed  by  acids,  a  great 
disadvantage  where,  in  the  form  of  terrazzo,  it  is  used  for 


832       THE   HEAD   NURSE   AND    WARD   MANAGEMENT 

the  flooring  of  operating-rooms  and  out-patient  depart- 
ments. If  any  acid  is  spilled,  it  should  immediately  be 
neutralized  with  an  alkali,  such  as  aqua  ammonia,  washing- 
soda,  etc. 

The  porcelain  and  enameled  iron  used  for  bath-tubs, 
basins,  and  sinks  is  frequently  wantonly  destroyed  by 
strong  alkalis  or  acids,  or  even  by  the  use  of  soaps  contain- 
ing pumice  or"  sand  or  strong  alkalis.  The  smooth  sur- 
faces become  roughened,  unsightly,  and  difficult  to  clean. 
If  it  is  necessary  to  soak  any  article  in  a  strong  alkali  or 
acid,  a  zinc  bucket  or  unpainted  wooden  tub  should  be 
used.  In  cleaning  tubs,  etc.,  grease  stains  that  have  been 
allowed  to  dry  are  difficult  to  remove  with  ordinary  soap- 
and-water  washing.  A  cloth  moistened  with  very  little 
turpentine  or  coal-oil  may  be  permitted.  Stains  from 
bichlorid  of  mercury,  permanganate  of  potash,  etc.,  will 
generally  yield  to  Labarraque's  solution.  Rust-marks,  or 
marks  from  dripping  of  hard  or  impure  water,  are  difficult 
to  remove,  and  may  require  an  application  of  one  of  the 
patent  soap  powders,  Porcella,  or  Bon-ami.  These  are, 
however,  proportionally  high  priced,  and  should  be  used 
only  when  "  elbow  grease  "  and  good  scrubbing  or  an  ap- 
plication of  Labarraque's  solution  have  failed. 

Stains  in  lavatory  sinks  and  water-closets  should  be 
treated  by  prevention.  They  do  not  occur  if  the  basins  are 
well  brushed  down  every  day,  and  always  well  rinsed 
after  use.  Labarraque's  solution,  or  Bon-ami,  or  Porcella 
will  usually  remove  all  such  marks. 

lodin  stains  may  usually  be  removed  by  a  paste  of 
starch  and  alcohol,  which  should  be  applied  at  once. 

Polished  Furniture. — In  the  private  room  of  a  hospital 
tables  and  bureau  of  highly  polished  woods  are  often  met 
with.  Like  all  furniture  in  constant  use,  they  are  liable 
to  become  dirty. 

Greasy  stains,  etc.,  may  be  removed  by  washing  with 
a  soft  cloth  in  warm  (not  hot)  soapsuds.  The  surface 
should  be  dried  and  rubbed  up  with  soft,  dry  cloths.  If 
the  polish  is  dimmed,  a  very  little  furniture  polish  may 
be  rubbed  on  with  a  flannel  and  rubbed  up  until  bright. 
A  polish  of  equal  parts  of  sweet  oil,  turpentine,  and 


DOMESTIC   WORK  833 

alcohol  is  serviceable  and  less  expensive  than  patent 
polishes. 

White  marks  on  polished  surfaces  are  removed  by  rub- 
bing quickly  with  a  flannel  soaked  with  a  small  quantity 
of  camphor  or  soap  liniment.  Another  method  is  to  place 
a  sponge  wrung  out  of  boiling  hot  water  exactly  on  the 
spot;  repeat  the  treatment  until  the  spot  is  effaced,  and 
then  rub  up  with  furniture  polish. 

If  the  surface  has  been  entirely  lost,  as  by  carelessly 
placing  very  hot  articles  (such  as  a  can  of  hot  water) 
directly  on  the  polished  wood,  it  is  generally  necessary  to 
send  the  furniture  to  a  dealer  to  be  repolished.  Olive  oil 
applied  with  very  small  absorbent  cotton  pledgets  and 
lightly  rubbed  into  the  wood  may  restore  the  polish,  but 
the  process  is  tedious  and  really  requires  expert  practice. 
Experience  shows  it  is  necessary  to  teach  nurses  not  to  place 
hot  articles  on  polished  wood. 

Alcohol  spilled  on  polished  wood  will  also  remove  the 
polish.  Olive  or  cottonseed  oil  should  be  poured  imme- 
diately over  alcohol  accidentally  spilled,  to  neutralize  the 
effect. 

Stains  on  Scrubbed  Wood. — Bad  grease  stains  are 
very  difficult  to  remove  entirely.  An  acid — oxalic  acid 
or  hydrochloric  acid — may  be  used  to  cut  the  grease,  fol- 
lowing which  the  stain  should  be  well  scrubbed  with  cold 
water  and  ammonia  and  sand  or  a  sand-soap. 

Ink,  if  spilled,  should  be  sopped  up  with  flour  at  once, 
and  may  then  be  treated  in  the  same  way  with  an  acid, 
followed  by  ammonia  and  sand-soap.  Small  spots  may  be 
covered  with  common  salt  and  rubbed  until  they  disappear 
with  a  squeezed  lemon. 

Blood-stains  on  absorbent  surfaces  are  apt  to  leave 
discolored  marks.  They  should  be  washed  in  cold  water 
before  they  become  dry,  in  order,  as  far  as  possible,  to 
dissolve  the  albumin.  Small  spots  on  wood  (as  on  linen, 
etc.)  may  be  completely  removed  with  peroxid  of  hydrogen, 
but  this  is,  obviously,  a  costly  method. 

lodin  should  be  treated  with  a  paste  of  starch  and  am- 
monia or  alcohol,  left  on  for  some  time,  and  washed  off  with 
ammonia  and  water  and  finally  thoroughly  rinsed. 

53 


834       THE   HEAD   NURSE   AND   WARD   MANAGEMENT 

Cleaning  of  Brass,  Copper,  and  Other  Metals. — Labor 
can  be  materially  saved  by  having  metal  work  coated  with 
lacquer,  a  process  carried  out  by  furniture-dealers.  This 
is  usually  done  for  brass  bedsteads  and  vessels,  etc.,  not 
in  constant  use,  but  is  unsuitable  otherwise,  as  washing  or 
exposure  to  heat  destroys  the  lacquer.  The  usual  metal 
polishes  also  destroy  lacquer,  and  nurses  and  ward-maids 
may  require  to  be  reminded  not  to  polish  lacquered  metals. 

One  or  other  of  the  patent  pastes  and  fluids  on  the  market 
for  polishing  brass,  copper,  and  zinc  are  commonly  used  in 
hospital  work.  As  they  are  expensive,  they  must  not  be 
used  extravagantly.  When  the  article  can  be  first  washed 
in  hot  soda  and  water,  a  smaller  quantity  of  the  polish 
will  be  necessary.  If  metal  work  is  polished  daily,  it  takes 
but  little  time  to  make  it  bright  or  clean. 

Brass  or  copper  that  has  become  very  dirty  is  best 
cleaned  with  a  strong  solution  of  oxalic  acid,  which  should 
be  removed  with  a  little  coal-oil. 

The  coal-oil  is  used  to  arrest  the  action  of  the  oxalic 
acid,  which,  if  continued,  would  destroy  the  metal  and 
helps  to  give  the  article  a  brighter  polish. 

While  metals,  silver,  nickel,  or  pewter,  are  most  eco- 
nomically cleaned  with  a  paste  of  whiting  and  water,  or,  if 
very  dirty,  of  whiting  moistened  with  ammonia. 

The  secret  of  well-kept  brights,  however,  lies  chiefly  in 
clean,  dry  polishing  rags  and  thorough  rubbing. 

Saucepans  and  Kitchen  Crockery. — Saucepans,  tea- 
kettles, and  such  homely  articles  in  enamelware  are  short- 
lived, indeed,  unless  a  special  point  is  made  of  their  care. 

Milk,  gruels,  cocoa,  and  foods  of  like  nature,  which 
readily  burn,  should  invariably  be  cooked  in  double 
boilers.  The  saucepan  is  then  easily  cleaned  with  hot 
water  and  a  little  soda,  whereas  if  burned,  the  violent 
rubbing  and  use  of  Sapolio  and  such  soaps  are  apt  to  chip 
the  enamel  and  make  further  burning  inevitable.  If 
burning  has  taken  place,  and  the  marks  do  not  readily 
come  away,  they  can  generally  be  removed  with  a  little 
salt  just  moistened  and  rubbed  on  the  spot  with  the  tips 
of  the  fingers.  If  this  is  not  sufficient,  an  application  of 
Labarraque's  solution  will  usually  be  effectual. 


DOMESTIC   WORK  835 

A  kettle  will  last  forever  if  not  put  on  the  stove  empty. 
Nurses  should  be  trained  invariably  to  replace  whatever 
water  they  take  from  a  kettle. 

Each  saucepan  should  be  cleaned  immediately  by  the 
nurse  who  has  used  it,  and  the  inspection  of  the  saucepans 
should  be  a  routine  part  of  the  daily  round. 

The  Ice-chest. — The  shelves  of  an  ice-chest  should  be 
removed  daily,  and  the  whole  interior  wiped  with  a  clean, 
damp  cloth.  Any  spills  must  be  removed  at  once.  Once 
a  week  the  whole  chest  should  be  well  scrubbed  with  strong 
soda  water  and  thoroughly  dried.  The  drain-pipe  must 
be  flushed  at  the  same  time  with  boiling  hot  soda  water, 
to  prevent  it  becoming  clogged.  Milk,  butter,  and  eggs 
should  not  be  kept  in  the  same  compartment  as  other 
foods.  Milk  and  butter  absorb  odors,  .and  pure  air  at  a 
low  temperature  is  essential  to  keep  eggs  fresh.  If  there 
is  only  one  ice-chest,  these  articles  must  be  closely  covered. 

Sinks  and  Hoppers. — To  keep  sinks  and  hoppers  free 
of  grease,  boiling  soda  water  should  be  poured  down  the 
soil-pipe  twice  a  week.  A  fine  wire-basket  strainer  kept  in 
each  sink  prevents  the  too  frequent  blocking  of  the  soil- 
pipe  by  lost  articles,  fluff  from  the  mops,  etc. 

A  not  infrequent  accident  with  taps  and  spigots  is 
the  sudden  giving  way  of  a  neglected  washer,  followed  by  a 
flood  of  water  that  cannot  be  checked.  Every  nurse 
should  know  the  points  at  which  the  water-supply  in  her 
department  can  be  temporarily  cut  off. 

The  Walls.— Except,  perhaps,  in  perfect  mechanical 
ventilation,  the  walls  of  a  ward  quickly  become  covered 
with  dust,  which,  if  undisturbed,  is  not  long  in  collecting 
cobwebs.  The  condition  is  minimized  by  the  use  of  highly 
varnished,  painted,  or  tiled  surfaces,  but  to  some  extent 
dust  on  the  walls  is  inevitable.  As  dust  in  a  ward  forms  a 
resting-place  for  germs,  it  is  necessary  that  the  dust  should 
be  removed. 

Each  week  the  walls  should  be  swept  down  with  a  soft 
broom  tied  in  a  bag  of  cheese-cloth  or  flannelette.  At 
longer  intervals  the  walls  may  be  washed,  using  a  large 
sea-sponge  or  soft  rags  and  plenty  of  clean  tepid  water. 
Bad  stains,  such  as  over  the  radiators,  may  require  a  little 


836       THE   HEAD   NURSE   AND   WARD   MANAGEMENT 

soap.  The  polished  surfaces  must  be  well  dried  and 
rubbed  with  soft,  dry  cloths  to  prevent  smearing. 

Greasy  marks  from  fingers,  heads,  etc.,  on  highly  var- 
nished paint  are  best  removed  by  rubbing  with  stale  bread. 

Beds  and  Bedding. — At  the  present  day  the  enameled 
iron  bedstead  has  practically  replaced  all  other  kinds  for 
hospital  use.  Fitted  with  a  chain  or  wire  mattress,  it  is 
comfortable,  easy  to  clean  and  handle,  and  with  care  in 
preventing  chipping  of  the  enamel,  wears  well.  It  has 
one  great  advantage  over  the  old  wooden  or  painted  iron 
bedsteads,  that  it  does  not  harbor  bedbugs. 

After  each  patient  goes  out,  the  enamel  part  of  the  bed- 
stead should  be  washed  in  warm  water  and  soap.  Stains 
may  be  removed  by  the  processes  already  described  for 
other  enameled  ironware.  The  use  of  a  disinfectant  is 
no  material  advantage,  since  it  cannot  remain  sufficiently 
long  in  contact  with  the  iron  to  be  in  any  sense  an  active 
agent. 

The  mattress  is  one  of  the  most  abused  of  articles 
in  hospital  equipment.  Wherever  necessary,  the  mattress 
should  be  protected  by  a  heavy  rubber  sheet  under  the 
linen  one,  covering  the  entire  mattress.  This  rubber 
should  constantly  be  inspected,  as  if  cracked  or  worn,  it 
is  no  longer  waterproof,  and  no  longer  of  any  use.  A  slip- 
cover of  unbleached  cotton,  which  can  be  changed  and 
washed,  should  always  be  used  to  keep  the  mattress  clean. 

Patients  with  chronic  incontinence  are  frequently 
nursed  on  straw  or  dried  grass  mattresses,  or  the  mattress 
is  dispensed  with  and  replaced  with  old  soft  blankets 
covered  with  a  rubber  sheet,  which  can  be  washed  when 
necessary. 

After  a  patient's  discharge,  the  mattress  should  be  taken 
in  the  open  air,  thoroughly  brushed  with  a  hard  whisk,  and 
left  in  the  sun  for  about  six  hours.  Before  being  used 
again  it  should  be  carefully  examined  and  sent  at  once  to 
the  repair  room  if  there  is  the  smallest  tear. 

Disinfection  can  properly  be  done  only  by  exposure  to 
high  temperature,  as  in  an  autoclave.  Where  this  is  not 
available,  exposure  to  the  fumes  of  formalin  is  considered 
suitable  for  most  cases.  This  is  not  usually  considered 


VENTILATION   AND   TEMPFJRATURE  837 

sufficient  if  the  case  has  been  one  where  the  infection  is 
spread  by  the  fomites,  as  in  smallpox  or  scarlet  fever. 

Stains  are  difficult  to  remove,  as  rinsing  in  water  will 
inj  ure  the  hair  or  flock  with  which  the  mattress  is  stuffed. 
Blood-stains  can  be  removed  with  peroxid  of  hydrogen. 
Other  stains  may  yield  tcr  washing  with  ammonia  and 
water;  the  part  washed  should  be  rubbed  as  dry  as  pos- 
sible and  instantly  exposed  to  sun  and  air  until  quite  dry. 
Mattresses  may  become  infested  with  bedbugs.  To  kill 
these  nothing  is  so  efficacious  as  the  fumes  of  sulphur. 
(See  Disinfection.)  Sulphur,  however,  will  not  destroy 
the  eggs;  in  bad  cases  the  mattress  may  have  to  be  de- 
stroyed; in  milder  cases,  the  hair  may  be  cleaned  at  an 
upholsterer's  and  sewn  into  fresh  ticking. 

Pillows,  either  of  hair  or  feathers,  should  be,  where 
necessary,  protected  from  soiling  or  wetting  (as  from  an 
ice-bag)  by  slip-cases  of  rubber.  These  should  not  be 
retained  unnecessarily,  as  they  are  heating  to  the  head. 
If  the  ticking  becomes  stained,  it  is  best  to  remove  the 
stuffing  and  have  the  soiled  ticking  washed  in  the  laundry. 

Surgical  Supplies. — The  care  of  rubber  goods,  instru- 
ments, and  special  surgical  appliances  is  discussed  in 
Chap.  XIII. 

VENTILATION  AND  TEMPERATURE 

The  necessity  for  a  constant  supply  of  fresh  air  and 
its  special  importance  in  the  hospital  ward  or  sick- 
room cannot  be  too  constantly  enforced.  It  is  a  point 
that  should  never  be  lost  sight  of,  and  will  require, 
unless  the  building  is  mechanically  ventilated,  constant 
personal  attention.  All  sources  of  impurity,  bed-pans, 
soiled  dressings,  etc.,  should  be  quickly  removed  from  the 
ward;  if  any  odor  is  perceptible,  the  adjacent  window 
should  be  opened  for  a  short  time. 

Garbage-cans  and  dressing-cans  are  a  source  of  impurity 
unless  kept  closely  covered  and  emptied  and  thoroughly 
cleaned  at  least  once  a  day.  The  galvanized  iron  cans 
with  closely  fitting  covers  commonly  used  are  the  most  san- 
itary available. 

The  temperature  of  the  ward  is  another  subject  re- 


838      THK    HEAD    NURSE   AND    WARD   MANAGEMENT 

quiring  constant  vigilance.  Wards  and  sick-rooms  should 
be  kept  as  nearly  as  possible  at  an  equal  temperature,  with 
little  variation  in  the  twenty-four  hours.  The  self-regis- 
tering thermometer  is  the  most  accurate  means  of  ascer- 
taining the  variations  of  temperature.  Where  the  or- 
dinary wall  thermometer  is  used,  the  temperature  of  the 
ward  should  be  recorded  every  four  hours.  The  record 
may  be  kept  in  the  form  of  a  chart,  like  a  clinical  chart,  or 
noted  in  a  small  copy-book  conveniently  ruled  for  the 
purpose.  The  chart  or  record  book  must  be  inspected 
daily  by  the  head  nurse,  and  from  time  to  time  checked  by 
her,  to  insure  its  accuracy. 

THE  VISITING  ROUNDS 

One  of  the  important  duties  of  a  head  nurse  is  to  accom- 
pany the  visiting  doctors  or  the  residents  on  their  rounds. 

She  must  make  a  point  of  being  fully  informed  as  to 
every  detail  concerning  her  patients.  Few  things  are  more 
trying  than  the  head  nurse  who  either  discovers  or  "  re- 
members "  facts  after  the  visit  is  over.  In  the  usual  eti- 
quette of  the  round  of  the  visiting  chief,  he  obtains  his 
information  concerning  the  patients  from  the  resident,  and 
the  head  nurse  is  required  to  report  only  if  directly  asked. 
If  there  should  be  some  information  to  report  which  she  has 
not  yet  been  able  to  communicate  to  the  resident,  she 
should  make  an  opportunity  of  telling  him  privately  of 
the  facts,  so  that  he  may  include  them  in  his  report. 

All  record  charts,  report  books,  and  the  day-book 
should  be  readily  available,  and  the  convalescent  patients 
eaqh  seated  by  his  own  bed.  Obviously,  talking  or  noise 
of  any  sort  is  out  of  place  during  a  round.  One  nurse 
(either  the  senior  or,  preferably,  the  nurse  in  charge  of  the 
cases)  should  accompany  the  head  nurse,  her  first  duty 
being  to  arrange  the  patients  for  examination  and  to  settle 
them  comfortably  afterward. 

The  other  nurses  should  continue  their  work  quietly; 
it  is  usually  considered  etiquette,  however,  that  they  should 
not  be  seated  during  the  round  unless  with  permission. 

In  a  surgical  ward  dressings  should  be  placed  in  readi- 
ness by  any  case  that  the  surgeon  may  be  expected  to  look 


THE    VISITING   ROUNDS  839 

at,  unless,  as  is  now  happily  often  the  case,  dressings  are 
done  in  a  room  especially  reserved  for  the  purpose,  and 
not  in  the  ward.  Lotions  and  water  should  be  already 
heated,  and  the  instruments  sterilized,  and  placed  ready 
for  use  in  a  sterile  towel.  By  such  forethought  a  great 
deal  of  time  may  be  saved. 

In  a  medical  ward  a  large  square  of  flannelette  or  some 
thin,  soft  material  should  be  at  hand  for  each  patient  when 
the  chest  is  examined.  Failing  this,  an  ordinary  towel  may 
be  substituted. 

To  the  nurse  is  intrusted  the  care  of  the  patients'  com- 
fort during  the  round.  It  should  not  be  left  to  the  doctor 
to  suggest  closing  a  window  during  a  dressing  or  examina- 
tion, or  placing  a  screen  to  obtain  privacy.  For  all  ex- 
aminations and  dressings,  however  slight,  a  screen  should 
be  placed  round  the  bed.  This  is  both  in  the  interest  of  the 
individual  patient  and  for  the  sake  of  his  fellows  in  the 
ward,  to  most  of  whom  the  sight  of  a  dressing  is  naturally 
repulsive.  This,  however,  is  a  point  on  which  both  nurses 
and  doctors  are  apt  to  become  careless,  and  it  is  for  the 
head  nurse  to  see  that  the  screens  are  used  when  necessary. 

In  touching  on  the  above  points  of  ward  management 
and  the  duties  and  responsibilities  of  a  head  nurse,  the 
subject  is  obviously  far  from  exhausted.  Even  the  con- 
struction of  the  hospital  may  alter  many  details  and  entail 
an  arrangement  of  duties,  etc.,  different  to  those  suggested. 
The  fundamental  fact,  however,  of  the  gravity  of  the  re- 
sponsibilities of  each  head  nurse,  and  the  immense  import- 
ance of  her  influence  on  others,  whether  for  good  or  ill, 
will  be  the  sam.e  under  whatever  conditions  she  under- 
takes her  work. 


APPENDIX 


RECIPES 

EXCEPT  where  the  recipes  have  been  taken  from  private  sources, 
the  quantities,  time,  etc.,  are  those  recommended  by  Miss  Farmer, 
in  her  book  on  invalid  cooking,  all  of  which  have  been  frequently 
tested. 

MILK 

Milk  is  pasteurized  by  being  kept  at  a  temperature  of  155°  to 
167°  F.  (66°-75°  C.)  for  thirty  minutes. 

A  double  boiler  must  be  used,  to  lessen  the  risk  of  the  temperature 
rising  too  high  or  of  the  milk  scorching. 

In  pasteurizing  milk  for  infants'  food,  the  amount  for  the  twenty- 
four  hours  is  divided,  and  each  feeding  placed  in  a  freshly  sterilized 
nursing-bottle.  The  bottles  are  arranged  most  conveniently  in  a 
bottle-rack,  and  are  placed  together  in  a  boiler  or  kettle  of  suitable 
size,  filled  with  sufficient  cold  water  to  rise  halfway  up  the  bottles. 
When  a  rack  is  not  used,  the  bottles  should  stand  on  a  folded  towel 
or  a  tray,  raised  a  little  from  the  bottom  of  the  kettle.  After  ex- 
posure to  the  required  temperature  for  half  an  hour,  the  bottles 
are  rapidly  cooled  and  placed  on  ice  until  required.  To  warm  the 
feedings,  the  bottle  is  placed  in  a  basin  of  hot  water. 

To  cool  quickly,  without  breaking  the  bottles,  remove  them  from 
the  kettle  and  place  in  a  pan  of  warm  water,  set  the  pan  under  the 
water-tap  and  let  it  run  over  the  bottles  first  warm,  and,  as  the  bot- 
tles cool  cooler,  until  the  water  in  the  pan  is  quite  cold;  then  place 
the  bottle  at  once  on  ice. 

There  are  many  patent  pasteurizers  on  the  market,  by  the  use  of 
which  the  process  may  be  carried  out  with  greater  exactitude. 

Where  the  process  has  to  be  entrusted  to  the  mothers  in  poor 
homes,  the  following  method  is  simple  and  reliable: 

Fill  a  soup  kettle  half  full  of  boiling  water;  place  the  bottles,  with 
the  feedings  measured,  in  the  kettle;  cover  closely  and  set  in  a  mod- 
erately warm  place  (an  average  room-temperature)  on  a  wooden 
table  for  half  an  hour;  remove,  cool  the  bottles  quickly,  and  place  in 
the  coldest  place  available,  on  ice  if  possible,  or  in  a  pan  of  cold 
water.  Wood  being  a  non-conductor,  helps  to  maintain  the  water 
at  an  even  temperature. 

To  Sterilize  Milk. — The  milk  is  kept  at  a  temperature  of  212°  F. 
(100°  C.),  i.  e.,  at  boiling-point,  for  thirty  minutes,  otherwise  the 
process  is  the  same  as  in  pasteurizing.  The  scum  which  forms  on 
the  milk  is  of  high  nutritive  value  and  should  be  reincorporated  by 
beating  with  an  egg  whisk. 

If  lime-water  is  used  with  either  pasteurized  or  sterilized  milk  in 
making  up  infants'  food,  it  must  be  added  after  the  process  is  com- 

840 


HECIPP:S  841 

plete.  The  action  of  lime-water  on  sugar  at  a  high  temperature  con- 
verts the  sugar  into  caramel,  giving  the  mixture  too  sweet  a  taste 
and  a  brown,  uninviting  appearance. 

To  Peptonize  Milk. — Various  preparations  are  in  use  for  the 
peptonizing  or  predigestion  of  milk,  each  of  which  is  accompanied  by 
full  directions  for  their  use. 

Fairchild's  peptonizing  powders  (extract  of  pancreas,  5  grains; 
bicarbonate  of  soda,  15  grains)  are  one  of  the  most  convenient 
methods,  and  are  generally  used  in  hospital  work. 

Dissolve  one  powder  in  4  ounces  of  cold  water.  Add,  when 
dissolved,  to  12  ounces  of  fresh  milk.  Set  in  a  pan  of  water  at  a 
temperature  of  105°  F.  (25°  C.),  and  keep  at  that  temperature  for 
fifteen  minutes. 

In  order  to  arrest  the  further  process  of  predigestion,  the  mixture  is 
then  either  brought  quickly  to  boiling-point  or  immediately  cooked 
(as  described)  and  placed  on  ice  until  required. 

Fully  peptonized  milk  is  extremely  bitter,  and  is  practically  used 
only  for  rectal  feeding  or  gavage. 

In  peptonizing  infants'  food,  dissolve  the  powder  in  4  ounces  of 
water,  and  use  half  an  ounce  of  the  peptonizing  fluid  to  every  two 
ounces  of  the  feeding. 

Koumiss. — Two  or  three  methods,  the  following  recommended  by 
Miss  Farmer: 

1    quart  milk.  i  yeast  cake. 

1 J  tablespoons  sugar.  1  tablespoon  lukewarm  water. 

Heat  the  milk  to  75°  F.  (24°  C.),  add  sugar  and  yeast  cake  dis- 
solved in  warm  water.  Fill  sterilized  bottles  to  within  one  and  a 
half  inches  of  the  top,  cork  tightly,  wiring,  if  necessary,  and  shake. 

Place  the  bottles,  upside  down,  in  a  temperature  of  about  70°  F. 
(21°C.)  for  ten  hours. 

Keep  for  forty-eight  hours  in  a  cold  place,  shaking  well  from  time 
to  time. 

Clabber,  or  Milk-jelly. — Set  one  quart  of  milk  in  a  covered  bowl 
on  the  back  of  the  kitchen  stove  until  the  milk  begins  to  turn ;  remove 
to  a  moderately  warm  place,  such  as  a  wooden  shelf  in  the  kitchen, 
until  firmly  set,  which  will  take  from  twelve  to  twenty-four  hours. 
Serve  with  cream  and  sugar  if  desired.  Clabber,  like  koumiss,  is 
usually  found  easy  of  digestion  and  is  generally  retained. 

Milk-curds,  or  Junket. — To  one  pint  of  sweet  milk,  at  a  tempera- 
ture of  about  100°  F.  (43.3°  C.),  add  two  teaspoons  of  liquid  rennet 
or  one-quarter  of  a  junket  tablet,  dissolved  in  a  little  cold  water. 
Stand  on  a  wooden  shelf  in  a  moderately  warm  place  until  set,  then 
place  on  ice.  Sprinkle  with  powdered  cinnamon,  and  serve  with 
cream  and  sugar. 

Whey. — To  extract  all  the  whey  from  junket,  proceed  as  described. 
When  the  curd  is  well  set,  break  it  up  thoroughly  with  a  silver  fork 
and  strain  through  cheese-cloth.  One  quart  of  milk  yields  about 
a  pint  and  a  half  of  whey. 

Whey  is  frequently  used  in  infant-feeding,  combined  with  cream, 
or  used  instead  of  water  in  a  modified  milk  formula.  Before  mixing 
with  cream  or  milk,  the  whey  and  the  milk  mixture  must  be  heated 
separately  to  a  temperature  of  150°  F.  (71°  C.),  and  then  mixed, 
otherwise  the  fermentative  action  of  the  rennin  will  curdle  the  fresh 
cream  or  milk. 

White  Wine  Whey. — As  above,  one  gill  of  sherry  to  a  pint   of 


842  APPENDIX 

milk  in  place  of  rennet.  Strain  and  serve  hot,  with  a  little  sugar  if 
preferred. 

Milk-punch. — Warm  half  a  pint  of  milk,  with  a  small  pinch  of 
salt  and  sugar  to  taste;  add  one  tablespoon  of  whisky,  brandy,  or 
rum. 

Buttermilk. — Strain  the  fluid  left  after  making  butter  into  a 
sterile  vessel.  Keep  on  ice  until  required. 

EGGS 

The  albumin  of  white  of  egg  is  soluble  hi  cold  water  and  coagulates 
in  water  at  a  temperature  of  134°  F.  (56.4°  C.).  If  it  is  exposed  to  a 
high  temperature,  it  becomes  tough,  leathery,  and  less  easy  of  diges- 
tion. In  cooking  eggs  for  the  sick-room  care  should  be  exercised  on 
this  point,  and  eggs  should  be  cooked  slowly,  at  a  moderate  temper- 
ature. 

A  soft-boiled  egg  is  the  most  easily  digested  form  in  which  eggs 
can  be  offered.  The  white  should  be  creamy  and  the  yolk  about  the 
consistency  of  jelly.  To  get  this  result  the  water  in  which  it  is 
cooked  should  not  be  above  175°  F. 

Soft-boiled  Eggs. — Place  in  a  covered  vessel  in  hot  water  (about 
175°  F.)  sufficient  to  cover  the  eggs,  and  stand  where  the  temperature 
will  not  be  rapidly  cooled  from  seven  to  ten  minutes.  Where  many 
eggs  are  cooked  together,  the  water  should  be  of  a  higher  temperature 
to  start  with  (185°  F.),  as  the  eggs  will  cool  it  considerably.  The 
eggs  should  be  tied  loosely  in  a  net,  so  that  they  may  all  be  placed  in 
the  water  and  taken  out  at  the  same  time. 

Hard-boiled  eggs  are  indigestible  unless  cooked  sufficiently  long 
that  when  removed  from  the  shell  the  yolk  is  easily  powdered. 
In  this  condition  they  are  as  easily  digested  as  when  soft  boiled. 
They  should  be  placed  in  water  at  about  175°  F.  and  kept  at  that 
temperature  for  forty-five  minutes. 

A  hard-boiled  egg  may  be  chopped  finely,  mixed  with  a  little  butter, 
seasoned  with  pepper  and  salt,  and  served  as  a  sandwich  with  thin 
bread  and  butter.  Chopped  parsley  or  anchovy  paste  may  be  added 
as  relishes. 

Scrambled  Egg. — Break  one  egg  in  a  bowl,  and  with  a  spoon  stir  hi 
a  tablespoonful  of  milk  and  a  pinch  of  salt.  Melt  half  a  tablespoonful 
of  butter  in  a  small  frying-pan,  add  the  mixture,  holding  the  pan  well 
above  the  flame,  so  that  it  cooks  slowly.  When  it  begins  to  set, 
break  up  with  a  fork  and  serve  hot  on  a  piece  of  crisp  toast.  Where 
permissible,  the  toast  may  be  spread  with  a  savory  paste,  such  as 
anchovy. 

Poached  Egg. — Slip  an  egg  out  of  the  shell  into  a  cup  or  large 
spoon  lightly  greased  with  a  little  butter,  place  it  in  a  saucepan  with 
hot  water  (about  175°  F.)  sufficiently  deep  to  cover  the  egg;  cook 
until  the  white  is  set.  Season  with  salt  and  pepper  and  serve  on  a 
small  piece  of  buttered  toast  and  garnish  with  a  sprig  of  parsley. 

Coddled  Egg. — Break  an  egg  in  a  cup  with  a  spoon,  add  5  ounces 
of  hot  milk  (about  165°  F.),  cook  in  a  double  saucepan,  stirring  con- 
stantly. Season  with  salt  and  pepper  and  serve  on  a  piece  of  toast. 

Shirred  Egg. — Use  an  egg-shirrer  or  a  small  custard  cup.  Mix 
a  spoonful  of  crumbs  with  a  little  butter;  grease  the  cup  lightly  with 
butter  and  sprinkle  with  bread-crumbs;  slip  the  egg  into  the  cup,  add 
a  sprinkling  of  salt,  and  cover  with  the  remaining  crumbs.  Bake  in  a 


KKCIPES  843 

moderate  oven  until  the  white  is  set;  garnish  with  a  sprig  of  parsley, 
and  serve  in  the  cup  in  which  it  is  cooked. 

Albumin-water. — The  white  is  the  most  easily  digested  portion 
of  the  egg;  being  soluble  in  cold  water,  it  may  frequently  be  given  in 
beverages. 

Break  the  albumin  up  by  stirring  with  a  spoon;  add  slowly,  while 
still  stirring,  half  a  pint  of  cold  water  and  a  small  pinch  of  salt. 

If  desired,  the  albumin-water  may  be  flavored  with  a  little  fruit 
syrup  or  the  juice  of  fresh  fruit.  Egg-albumen  may  also  be  given 
in  sweet  milk  or  in  whey,  instead  of  in  water. 

Wine  and  Egg-albumen. — Beat  the  white  of  one  egg  stiff  with  a 
knife,  adding  gradually  about  two  teaspoons  of  powdered  sugar;  add, 
still  Iieating,  a  wineglass  of  sherry,  port,  claret,  or  other  still  wine; 
serve  in  wide  wineglass  on  crushed  ice  with  a  spoon. 

Meringues. — Beat  the  whites  of  two  eggs  until  stiff  with  a  knife, 
and  fold  in  half  an  ounce  of  powdered  sugar;  drop  from  a  teaspoon 
in  small  heaps  on  to  a  wet  board;  bake  in  a  quick  oven  until  lightly 
colored.  Served  with  cream,  either  plain  or  ice-cream,  they  form  a 
tempting  desert  in  a  restricted  diet. 

Eggnog. — Beat  one  egg,  adding  gradually  half  a  tablespoon  of 
powdered  sugar,  a  pinch  of  salt,  and  one  tablespoon  of  brandy  or 
three  of  sherry;  when  well  mixed,  add  ice-cold  milk  to  eight  ounces. 

If  preferred,  the  white  may  be  beaten  separately  until  stiff,  and 
added  on  the  top  of  the  glass  containing  the  eggnog. 

Eggnog  with  Coffee,  Tea,  or  Cocoa. — Break  the  egg  with  a  spoon, 
adding  sugar  and  a  pinch  of  salt.  Stir  into  a  little  cold  milk,  and 
add  to  a  cup  of  coffee,  tea,  or  cocoa. 

GRUELS 

Oatmeal  Gruel. — Into  a  pint  of  boiling  water  run  through  the 
fingers  two  heaped  tablespoons  of  oatmeal  and  a  pinch  of  salt,  stirring 
all  the  time;  allow  to  boil  briskly  for  two  minutes,  then  cook  slowly 
in  a  double  saucepan  for  one  hour,  stirring  from  time  to  time;  strain, 
thin  to  required  consistence  with  hot  (not  boiled)  milk,  and  serve 
very  hot.  Cream  may  be  added  when  desirable. 

Barley  Gruel. — Make  one  tablespoon  of  barley  flour  into  a  paste 
with  a  little  cold  water;  add  to  one  pint  of  boiling  water  while  stirring, 
and  boil  fifteen  minutes;  strain,  add  hot  milk,  allow  to  reheat  to- 
gether and  serve  hot. 

Arrow-root. — Dissolve  two  teaspoons  of  arrow-root  in  a  little  cold 
water,  place  in  a  double  saucepan,  and  add  half  a  pint  of  hot  milk 
and  a  pinch  of  salt;  stir  over  the  fire  until  it  thickens;  then  allow 
to  cook  slowly  for  ten  minutes;  serve  hot  with  sugar  to  taste;  sprinkle, 
if  desired,  with  a  little  nutmeg  or  cinnamon. 

Cracker-gruel. — Crush  a  couple  of  plain  crackers  into  crumbs 
and  bake  in  a  slow  oven  until  quitft  brown,  in  order  to  dextrinize 
the  starch;  add  to  half  a  pint  of  hot  milk  with  a  pinch  of  salt,  and 
cook  in  a  double  saucepan  about  five  minutes. 

Rice-gruel.— Wash  one  tablespoon  of  rice  and  stand  for  about 
two  hours  in  cold  water;  pour  off  water;  add  rice  to  cold  milk,  and 
cook  in  a  double  saucepan  for  an  hour  and  a  half;  strain,  add  salt, 
and  serve  either  hot  or  cold. 

Rice-flour  Gruel. — Make  one  tablespoon  rice  flour  into  a  paste 
with  a  little  cold  water  and  add  to  a  pint  of  hot  milk  with  a  pinch 


844  APPENDIX 

of  salt.  Cook  in  a  double  saucepan  for  fifteen  minutes.  Add  sugar 
to  taste,  and  flavor,  if  desired,  with  cinnamon  or  nutmeg. 

Apple-gruel. — Pare,  core,  and  cut  up  a  large  apple;  cover  with  one 
pint  of  boiling  water,  and  simmer  slowly  until  reduced  to  a  pulp; 
then  strain.  Mix  one  tablespoon  of  arrow-root  with  cold  water,  and 
stir  into  the  hot  apple  water  until  it  boils.  Boil  two  minutes,  then 
cook  slowly  in  a  double  saucepan  for  three  minutes;  flavor,  if  desired, 
with  a  little  lemon-juice.  Sugar  should  be  used  sparingly. 

Flour-gruel  (Pap). — Make  two  tablespoons  of  flour  or  corn-starch 
into  a  paste  with  cold  water  and  add  to  a  pint  of  hot  milk.  Add  a 
pinch  of  salt  and  cook  for  twenty  minutes  in  a  double  saucepan. 
Add  sugar  to  taste,  and  flavor  with  nutmeg  or  cinnamon,  if  desired. 

In  making  the  above  gruel  and  other  farinaceous  foods  patent 
starch  preparations  are  frequently  used  instead  of  the  raw  articles, 
and  require  less  time  for  cooking,  as  the  starch  is  already  partially 
dextrinized.  Directions  for  their  use  accompany  each  package. 
Robinson's  patent  foods  are  always  reliable. 

Oatmeal  Jelly. — Set  two  ounces  of  oatmeal  in  one  quart  of  cold 
water  and  allow  to  soak  about  twelve  hours;  bring  to  the  boil,  and 
cook  slowly  down  to  one  pint;  strain  while  hot,  and  leave  in  a  cold 
place  to  set. 

Barley  Jelly. — Wash  one  ounce  of  pearl  barley  in  cold  water  until 
clean;  add  to  one  quart  of  cold  water,  and  boil  slowly  down  to  one 
pint ;  strain  while  hot,  and  leave  in  a  cold  place  to  set. 

Dextrinized  Flour  With  Buttermilk  (For  Infant-feeding). — 
Wheat  flour,  4  ounces  (by  measure) ;  cold  water,  one  pint.  Mix  the 
flour  to  a  smooth  paste  in  a  little  of  the  water;  put  the  remainder  on 
the  fire  in  a  double  saucepan.  When  boiling,  stir  in  the  flour  and 
allow  to  boil  twenty-five  minutes,  stirring  occasionally  to  keep 
smooth. 

Take  from  fire;  cool  down  to  between  140°  and  160°  F.  Then 
add  two  teaspoons  of  "  Cereo  "  (a  patent  preparation) ;  stir  for  ten 
minutes,  keeping  the  mixture  at  an  even  temperature.  To  each  ounce 
of  the  mixture  add  half  an  ounce  of  cane-sugar,  stirring  until  dis- 
solved. Strain  through  cheese  cloth  and  put  on  ice. 

Add  to  fresh  buttermilk  just  before  feeding,  in  the  proportion  of 
half  a  dram  of  Cereo-sugar  mixture  to  each  ounce  of  buttermilk. 

Dextrinized  Barley-gruel  (For  Infant-feeding). — Barley  flour,  one 
heaping  tablespoon;  boiling  water,  one  pint.  Mix  the  flour  to  a  paste 
with  cold  water;  add  to  the  boiling  water,  and  boil  for  fifteen  minutes, 
stirring  occasionally.  Cool  as  above,  and  add  Cereo  as  in  flour 
mixture.  Add  two  ounces  of  cane-sugar  to  one  pint  of  gruel.  Strain, 
and  keep  on  ice.  Give  with  whey  in  the  proportion  of  two  parts  gruel 
to  one  of  whey.  The  two  last  recipes  (from  the  Philadelphia  Chil- 
dren's Hospital  dietary)  are  valuable  substitutes  for  milk  in  cases  of 
protein  indigestion. 

MEAT-TEAS,  ETC. 

Beef-juice. — From  half  a  pound  of  lean,  tender  steak  remove  all 
fat.  Broil  on  both  sides  over  a  hot  fire  for  four  minutes,  turning 
quickly  at  first  to  seal  the  juices.  Cut  into  small  pieces,  and  squeeze 
through  a  lemon-squeezer  or  meat-press  into  a  warm  cup.  Stand 
the  cup  in  water  about  130°  F.  until  the  juice  is  warmed  through, 
but  not  cooked,  and  season  with  salt.  Serve  at  once.  If  to  be  kept, 


RECIPES  845 

the  juice  is  seasoned  with  salt  and  placed  on  ice,  but  not  reheated  until 
required.  It  may  also  be  taken  iced,  or  added  to  milk  if  desired. 

Beef-tea. — From  one  pound  of  lean,  tender  steak  from  the  round 
remove  all  fat  and  cut  up  in  small  pieces;  place  in  jar,  add  one  pint  of 
cold  water,  and  cover  closely.  Stand  the  jar  in  a  kettle  of  cold  water 
also  covered.  The  water  in  the  kettle  should  be  sufficient  com- 
pletely to  surround  the  contents  of  the  jar;  unless  a  double  boiler  is 
used,  the  jar  should  be  raised  from  the  bottom  of  the  kettle  on  an 
inverted  saucer,  etc.  Bring  the  water  in  the  kettle  slowly  to  a  tem- 
perature of  130°  F.,  and  keep  about  that  temperature  for  two  hours; 
then  raise  to  170°  F.  until  the  beef-tea  becomes  brown,  in  order  to 
remove  the  unpleasant  raw  taste.  Remove  the  meat  and  season 
with  salt. 

In  warming  before  serving  care  must  be  taken  not  to  boil  any 
meat  preparation. 

Chicken-tea. — Use  a  whole  spring  chicken;  clean,  disjoint,  and 
remove  the  skin  and  fat.  Put  in  a  kettle  of  cold  water,  one  pint  to 
each  pound,  and  bring  slowly  to  boiling-point.  Add  salt  and  pepper 
and  cook  slowly  until  the  meat  is  tender,  skimming,  when  necessary. 
Strain  and  remove  the  fat.  Serve  with  a  little  well-boiled  rice  and 
chopped  parsley,  heated  with  the  broth;  or,  if  preferred,  with  a 
beaten  egg  or  thick  cream,  in  the  proportion  of  one  egg  or  one  table- 
spoon of  cream  to  half  a  pint  of  broth. 

Mutton-broth. — Take  three  pounds  of  lamb  or  tender  mutton  from 
the  forequarter;  remove  skin  and  fat,  and  cut  up  in  small  pieces;  put 
in  a  kettle  with  three  pints  of  cold  water.  Bring  gradually  to  boiling- 
point;  add  salt,  and  cook  slowly  until  meat  is  tender,  skimming  when 
necessary.  Strain  and  remove  fat. 

Serve  with  a  little  well-boiled  rice  or  barley  and  chopped  parsley. 

BEVERAGES 

Lemonade. — Squeeze  the  juice  of  one  or  two  lemons  with  a  lemon- 
squeezer;  add  powdered  sugar  to  taste,  and  dilute  with  iced  water, 
either  plain  or  carbonated;  serve  with  a  slice  of  lemon  or  a  cherry  or 
whole  strawberry.  Drink  through  straw. 

Lemonade  may  also  be  made  with  hot  water  in  the  same  way,  and 
taken  hot.  In  this  way  it  induces  sweating  and  is  serviceable  for 
breaking  up  colds,  etc.  The  juice  of  oranges  or  the  strained  juice  of 
crushed  fresh  strawberries,  grapes,  or  currants  may  be  used  in  the 
same  way. 

Where  a  high  caloric  diet  is  being  used,  milk-sugar  may  be  used 
in  place  of  cane-sugar.  In  this  case  the  milk-sugar  is  dissolved  in  a 
little  cold  water  and  boiled  for  two  minutes  (p.  791);  the  amount  of 
the  sugar  solution  added  depends  on  the  quantity  of  milk-sugar  to 
which  the  patient  has  become  accustomed. 

Imperial  Drink. — To  each  pint  of  lemonade,  made  as  above,  add 
one  heaped  teaspoon  of  cream  of  tartar;  stir  until  dissolved.  Useful 
in  conditions  of  deficient  elimination,  especially  when  the  kidneys  are 
affected,  and  may  be  taken  freely. 

Barley-water. — Wash  two  tablespoons  of  pearl  barley  in  cold 
water;  place  in  half  a  pint  of  cold  water,  and  bring  to  the  boil; 
throw  the  water  away,  add  two  pints  of  cold  water,  bring  to  the 
boil,  and  allow  to  simmer  gently  until  reduced  to  one  pint ;  strain,  and 
serve  ice  cold  with  a  little  lemon-juice  and  sugar.  Barley-water 


846  APPENDIX 

unflavored  is  frequently  ordered  in  the  place  of  water  to  dilute 
the  milk  for  the  infant-feedings,  or  as  a  substitute  for  milk  in  cases 
of  intestinal  irritation. 

Rice-water  may  be  made  in  the  same  way,  and  is  also  useful  in 
cases  of  intestinal  irritation.  In  these  conditions  beverages  are  usu- 
ally ordered  cold. 

Oatmeal  water  is  also  made  in  the  same  way  (oatmeal,  half  an 
ounce,  to  one  quart  of  water),  and  is  ordered  chiefly  for  rectal  irri- 
gation in  certain  irritated  conditions  of  the  intestines. 

Rice-milk. — Wash  two  tablespoons  of  rice  in  cold  water  and  soak 
hi  one  pint  of  cold  water  half  an  hour;  bring  gradually  to  boiling- 
point  and  cook  slowly  until  the  rice  is  soft;  strain  and  dilute  with 
hot  milk  or  cream ;  season  with  salt  or  sweeten  with  sugar,  as  preferred. 

Flaxseed-tea  (Linseed-tea). — Wash  one  ounce  of  whole  flaxseed 
and  pour  over  it  one  quart  of  boiling  water;  simmer  to  half  the  quan- 
tity; strain  and  add  the  juice  of  one  lemon  and  sugar  to  taste. 

Frequently  ordered  in  inflammatory  conditions  of  the  kidney. 
As  a  soothing  drink  and  mild  expectorant  in  bronchial  affections  it 
is  often  ordered  with  the  addition  of  a  small  quantity  of  licorice  root 
(about  two  drams),  cooked  with  the  flaxseed. 

Without  flavoring,  flaxseed  tea  is  also  used  as  a  rectal  irrigation. 

Toast-water. — Toast  two  slices  of  bread  crust  and  crumb  to  a 
dark  brown;  place  in  a  deep  dish  and  pour  over  it  one  quart  of  boiling 
water;  cool  and  when  cold,  strain. 

Serve  cold;  flavor  if  desired  with  lemon-juice  or  serve  with  a  slice 
of  lemon.  Toast-water  is  often  effectual  hi  relieving  nausea. 

Ginger-tea. — Mix  half  a  teaspoon  of  ginger  in  a  tablespoonful  of 
molasses,  add  a  cup  of  boiling  water,  and  allow  to  boil  one  minute. 

If  preferred,  half  the  quantity  of  water  may  be  used  and  the  amount 
made  up  with  hot  milk.  Useful  as  a  carminative  in  dyspeptic  flat- 
ulence and  to  relieve  abdominal  cramps. 

Cocoa  or  Baker's  Powdered  Chocolate. — Mix  a  teaspoon  of  cocoa 
into  a  paste  with  a  little  cold  water,  add  half  a  cup  of  boiling  water, 
sufficient  sugar  to  taste,  and  a  very  small  pinch  of  salt ;  boil  for  one 
minute,  stirring  constantly;  add,  while  still  stirring,  half  a  cup  of 
scalded  milk,  and  pour  into  a  heated  cup. 

A  larger  proportion  of  milk  may  be  used  if  preferred,  or  a  spoonful 
of  whipped  cream  can  be  added. 

A  few  drops  of  essence  of  vanilla  placed  in  the  cup  before  the 
cocoa  or  chocolate  is  poured  will  give  additional  flavor. 


INDEX 


ABBE  condenser,  397 

Abbreviations,  347 

A.  B.  and  S.  pills,  350 

A.  B.  C.  antiseptic  douche,  174,  463 

Abdomen,  appearance  of,  as  symptom, 

221 

dropsy  of,  paracentesis  in,  529 
many-tailed  bandage  of,  299 
operations  on,  sterilization  in,  474 
Abdominal  binder,  300 
breathing,  213 

restricted,  213 

dressing,  adhesive  strapping  of,  327 
section,  bowel  movements  after,  578 
diet  after,  576,  577 
distention  of  intestine  after,  579 
drainage  after,  577 
hemorrhage  after,   581.        See  also 
Hemorrhage  after  abdominal  sec- 
tion. 

intestinal  obstruction  after,  579 
position  after,  576 
postoperative  care,  575 
sepsis  after,  583 
shock  after,  581 

early,  581 

tympanites  after,  580 
visitors  after,  579 
Abscess,  121,  441 
Absorption  of  food,  755 
Absorptive  activity  of  stomach,  deter- 
mining, 259 

Accident  wounds,  cleansing,  651 
Accidental  rashes,  731 
wounds,  shock  in,  650 

treatment,  650 
Accidents,  592 
Acetanilid  as  antiseptic,  460 
overdose  of,  treatment,  383 
poisoning  by,  treatment,  383 
Acetic  acid  in  hemorrhage,  608 
Acid,  boric,  as  antiseptic,  458 
as  ear  douche,  177 
as  vaginal  douche,   174 
carbolic,  as  antiseptic,  456 
color  of  urine  from,  273 
poisoning  by,  treatment,  373 
definition  of,  341 
dilute,  dosage  of,  347 
from  bacteria,  390 
hippuric,  in  urine,  271 
hydrocyanic,  poisoning  by,  375 
muriatic,  349 
nitric,  poisoning  by,  373 
organic,  744 

oxalic,  poisoning  by,  treatment,  373 
phosphoric,  in  urine,  271 


Acid,  prussic,  350 

salicylic,  full  doses,  symptoms  of,  386 

in  rheumatic  fever,  433 
stains  for  bacteria,  399 
sulphuric,  in  urine,  271 

poisoning  by,  373 
uric,  in  urine,  270 
Acidity  of  gastric  juice,  259 
Acne  rash,  731,  733 
Aconite,  overdose  of,  treatment,  382 

poisoning  by,  treatment,  382 
Acupressure  in  hemorrhage,  606 
Acupuncture  in  external  hemorrhage, 

612 

Acute  anterior  poliomvelitis,  711 
Adhesive  plaster,  154,  323 
strapping,  323 

in  fracture  of  clavicle,  325 

of  ribs,  324 
in  sprains,  326 
in  ulcer  of  leg,  326 
of  abdominal  dressing,  327 
of  ankle,  327 
of  wounds,  327 
Adrenalin  chlorid  in  epistaxis,  619 

in  hemorrhage,  608,  609 
Adventitious  sounds,  224 
Aerobic  bacteria,  389 
Aerogenic  bacteria,  390 
Affusion,  cold,  115 
Agar-agar  as  culture-media,  405 
Age,  influence  of,  on  dosage,  342 
Agglutination  of  bacteria,  427 

of  typhoid  bacillus,  402 
Agglutinins,  427 

Air,  exposure  to,  in  hemorrhage,  598 
Air-bed,  82 
Air-borne  diseases,  412,  415 

prophylaxis,  417 
Air-hunger,  212 
Air-pump,  sterilization  of,  482 
Albumin  in  urine,  279 

Esbach's    albuminometer    for    esti- 
mating amount,  279 
Heller's  test  for,  279 
of  meat,  effect  of  cooking  on,  760 
Albuminoids,  741 

effect  of  cooking  in,  760 
Albuminometer,  Esbach's,  279,  2SO 
Albuminuria,  279.        See  also  Albumin 

in  urine. 

Albumin-water,  843 
Alcohol  as  antiseptic,  459 

dilute,  for  rubbing  purposes,  459 
in  hemorrhage,  611 
poisoning  by,  treatment,  382 
time  of  administering,  345 

847 


848 


INDEX 


Alcoholic  drinks,  781 

solution    of    bichlorid    of    mercury, 

Harrington's,  463 
Alcoholism,  convulsions  in,  679 
Alexins,  427 
Algid  collapse,  194 
Alkali,  definition  of,  341 
Alkaline  bath,  105 

stupe,  139 

urine,  272 

Alkalis  from  bacteria,  390 
Alkaloid,  definition  of,  341 

of  coca,  poisoning  by,  treatment,  384 

putrefactive,  408 
Alum  enema,  165 

in  hemorrhage,  608 

Ameboid  movements  of  leukocytes,  251 
Ammonia,  action  of,  344 

as  vesicant,  151 

carbonate  as  emetic  in  poisoning,  371 

fumes,  inhalation  of,  364 
Ammoniacal  urine,  273 
Amyl  nitrite  vapor,  inhalation  of,  365 
Amylopsin,  752,  753 
Amyloses,  741 
Anacidity,  gastric,  259 
Anaerobic  bacteria,  389 
Analgesic,  definition  of,  341 
Analgesics,  702 
Anasarca,  712 

Anemia    after   hemorrhage,    treatment, 
612 

color  of  skin  in,  245 

diet  in,  803 

dropsy  in,  712 

malignant,  color  of  skin  in,  245 

pernicious,  color  of  skin  in,  245 
Anesthesia,  358,  702 

chloroform,  359 

ether,  360,  568 

closed  method,  361 
open  method,  362 
primary,  362 
profound,  363 
semi-open  method,  362 
stages  of,  362 
surgical,  363 

ethyl  bromid,  364 
chlorid,  364 

examination  before,  363 

local,  364 

nitrous  oxid,  359 
Anesthetic,  definition  of,  341 
Anesthetist's  table,  541 
Aneurysm  needle,  480 
Angular  splint,  312 
anterior,  313 
internal,  312 
Anhydrotics,  722 
Animal,  bite  of,  671 

rabid,  bite  of,  671 

starch,  741 

Animals,  heat-stroke  in,  699 
Ankle,  adhesive  strapping  of,  327 
Ankylosis  from  fracture,  627 
Ankylostomum  duodenale,  395 
Anodyne,  702 

definition  of,  341 

Hoffman's,  349 

plaster,  153,  154 
Anopheles,  transmission  of  malaria  bv, 

394 
Antepartum  hemorrhage,  620 


Anthelmintic,  definition  of,  341 
Anthrax   bacillus,   spore   formation   in, 

394 
Antidote,  369 

chemical,  369 

dosage  of,  344 

physiologic,  370 
Antifebrin,  overdose  of,  treatment,  383 

poisoning  by,  treatment,  383 
Antihydrotic,  definition  of,  341 
Antimony,  wine  of,  350 
Antiphlogistine,  154 
Antipyretic,  195 

definition  of,  341 
Antipyrin,  overdose  of,  treatment,   383 

poisoning  by,  treatment,  383 
Antisepsis,  443 

theory  of,  409 
Antiseptics,  444,  454 

A.  B.  C.  douche,  174,  463 
acetanilid,  460 

alcohol,  459 

B.  B.  C.  powder,  460 
bichlorid  of  mercurv,  454 

'  blue  stone,  460 
boric  acid,  458 
carbolic  acid,  456 
chlorin,  461 
chlorinated  lime,  462 

soda,  462 

copper  sulphate,  460 
corrosive  sublimate,  454 
creolin,  457 
formaldehyd,  462 
formalin,  462 

Harrington's  alcoholic  solution  of  bi- 
chlorid of  mercury,  463 

iodin  solution,  463 
hydrargyrum   chloridum   corrosivum. 

454 

hydrogen  peroxid,  458 
iodoform,  459 
lunar  caustic,  460 
lysol,  457 
milk  of  lime,  461 
normal  salt  solution,  460 
permanganate  of  potash,  458 
phenol,  456 

precautions  in  using,  463 
salt  solution,  normal,  460 
silver  nitrate,  460 
Thiersch's  solution,  463 
whitewash,  461 
Antistreptococcus  serum,  425 
Antitoxin,  425 
diphtheria,  425 
immunity  unit,  426 
measurement  of,  426 
serums,  injection  of,  521 
technic  of  producing,  426 
tetanus,  425,  443 

in  tetanus,  661 
Anuria,  274 
Anus,  155 

Aperient,  definition  of,  341 
Apomorphin    as    emetic    in    poisoning 

371 

Apothecaries'  fluid,  331 
measures,  330 

changing  of,  to  metric,  338 

measuring  solutions  by,  469 
weight,  330 

equivalent  in  metric  system,  337 


INDEX 


Appendix,  840 
Apple-gruel,  844 
Applicators,  vaginal,  237 
Aquae,  dosage  of,  346 
Arm  bath,  99,  100 

four-cornered  bandage  for,  302 

handkerchief  bandage  of,  304 

sling  for  support  of,  304 

support  of,  by  hand,  288 

three-cornered  bandage  for,  302 

upper,    fracture    of,    treatment,    im- 
mediate, 632 

Arms,  patient's,  position  of,  on  operat- 
ing-table, 551 
Arnold  sterilizer,  449 
Aromatic  substances  in  urine,  271 
Arranging  patient  in  bed,  89 
Arrow-root,  843 
Arterial  hemorrhage,  594 

tension,  203 
Arteries,    common    carotid,    taking    of 

pulse  at,  202 
Arteriosclerosis,  203 
Artery,  brachial,  digital  compression  of, 
598 

facial,  compression  of,  603 
taking  of  pulse  at,  202 

femoral,  digital  compression  of,  602 
taking  pulse  at,  202 

radial,  compression  of,  at  wrist,  600 
taking  pulse  at,  202 

subclavian,  compression  of,  601 

temporal,  pressure  of,  602 
taking  of  pulse  at,  202 

ulnar,  compression  of,  at  wrist,  600 
Artificial     respiration,     690.     See     also 

Respiration,  artificial. 
Asafetida  enema,  165 
compound,  165 

in  intestinal  distention  after  abdomi- 
nal section,  580 

plaster,  153 
Ascites,  712 

paracentesis  in,  529 
Asepsis,  446 
Ash,  747 

Asparagus,  odor  of  urine  from,  273 
Asphyxia,  690 

artificial  respiration  in,  690 

caused    by    drowning,    artificial    res- 
piration in,  692 

causes  of,  690 

of  newborn,  694 

artificial  respiration  in,  694 
Byrd's  method,  695 
Sehultze's  method,  694 

white,  of  new-born,  696 
Aspiration,  530 

of  chest-wall,  535 

of  pericardium,  535 

of  peritoneal  cavity,  531-533 

of  pleura,  534,  535 
Aspirator,  531 

Asthma,  inhalation  of  saltpeter  for,  365 
Astringent,  definition  of,  341 

enema,  166 

enteroclysis,  169 

in  hemorrhage,  608 
Atrophy,  248 
Atropin,  effect  of,  on  eye,  240 

in  hemorrhage,  611 

in  pain  after  eye  operations,  585 

in  poisoning  by  opium,  385 

54 


Atropin  in  respiratory  failure   in   ether 

anesthesia,  363 
in  shock,  593 

after  abdominal  section,  581 
Attenuated  virus,  inoculation  with,  424 
Atwater's  estimation  of  caloric  value  of 

food,  748 
Aura,  679 
Auscultation,  224 
Autoclave,  450,  451 
Auto-infusion  in  hemorrhage,  611 
Avoirdupois  weight,  331 

equivalent  in  metric  system,  337 
Axilla,  glands  of,  operations  on,  steriliza- 
tion in,  475 
taking  temperature  in,  201 


BACILLUS,  390,  391,  392 

anthrax,  spore  formation  in,  394 

drumstick,  390,  392 

hay,  393 

Klebs-Loffler,  392 

of  tetanus  in  surgery,  442 

potato,  393 

pyocyaneus,  440 

wound  infection  by,  656 
spindle-shaped,  392 
spore  of,  392,  393 
tetanus,  spore  formation  in,  394 
tubercle,  393 

Gabbett's  stain  for,  400 
typhoid,  393 

agglutination  of,  402 

Widal  reaction  of,  401 
Back,  care  of,  77 

splint,  311 

Bacteria,  387,  388,  389 
acids  from,  390 
aerobic,  389 
aerogenic,  390 
agglutination  of,  427 
alkalis  from,  391 
chromogenic,  390 
anaerobic,  389 
avenues  of  entrance,  407 
classification,  387 

by  characteristics,  390 

by  shape,  391 
cu|ture  of,  402 

instruments  for  making, .  404 
culture-media  for,  402 
examination  of,  396 
facultative,  389 
fission  of,  388,  393 
food  of,  389 
hanging-drop    method  of   examining, 

401 

in  blood,  obtaining  of,  for  culture  pur- 
poses, 527 
in  epithelium,  414 
in  feces,  269 

in  typhoid  fever,  269 
jn  lungs,  413 
in  mouth,  413 
in  nose,  413 
in  secretions,  414 
in  surgery,  439 
in  throat,  413 

Koch's  postulates  for,  410,  411 
modes  of  transmission,  412 
morphology,  391 
motility  of,  393 


850 


INDEX 


Bacteria,  non-pathogenic,  389 
obligate,  389 

oscillating  movements,  393 
pathogenic,  389 

action  of,  431 
photogenic,  390 
plating,  403 

preparation  of  specimens  for  examina- 
tion, 398 
pyogenic,  439 

incubation  period,  442 
reproduction  of,  393 

vegetative,  393 
smear-culture,  398 
staining  of,  398 

precautions,  399 
strict,  389 

temperature  favorable  to  growth,  390 
transmission  of,  modes,  412 
zymogenic,  390 
Bacterial  casts  in  urine,  276 
Bacteriology,  387 

surgical,  439 
Bacteriolysis,  427 
Bag,  bran,  130 
hot-water,  128 
ice-,  125 
Politzer's,  244 
salt,  130 

Baker's  powdered  chocolate,  846 
Baking,  sterilization  by,  448 
Ball  syringe,  157 
Balsam,  Friar's,  350 
Bandage,  286 
Barton's,  294 
capeline,  295 
crinolin,  286,  287 
Esmarch  rubber,  287 
figure-of-8,  290 

of  both  shoulders,  290 

of  breast,  295 

of  eye,  293,  294 

of  foot,  291 

of  hand,  292 

of  instep,  291 

of  jaw,  294 

of  nape  of  neck,  295 

posterior,  290 
four-tailed,  298 

of  arm,  302 

of  jaw,  298 
gauze,  287 
handkerchief,  301 

of  arms,  303 

of  chest,  303 

of  foot,  303 

of  hand,  303 

of  head,  302 

of  hip,  303 

of  perineum  and  hip,  302 

of  shoulder,  303 

of  stump,  303 

to  prevent  motion  of  arm,  303 
many-tailed,  298 

of  abdomen,  299 
of  eye,  293 
of  fingers,  292 
of  head,  295 

recurrent,  296 
of  heel,  292 
of  jaw,  294 
of  stump,  293 

recurrent,  293 


Bandage,  plaster-of-Paris,  304 
interrupted,  305,  306 
opening  in,  305 
technique  of  applying,  304 
reverse  spiral,  289 

of  lower  extremity,  289 
of  upper  extremity,  289 
roller,  282 

machine  to  roll,  287 
rules  for,  288 
rubber,  Esmarch,  287 
Scultetus,  298 
silicon,  308 
spica,  of  groin,  291 
of  instep,  291 
of  pelvis,  291 
of  shoulder,  290,  291 
of  thumb,  292 
spiral,  reversed,  289 

of  lower  extremity,  289 
of  upper  extremity,  289 
simple,  289 
starch,  307 
stiff,  304 
T-,  297 

three-cornered,  for  arm,  302 
tortuous,  292 
triangular,  301 
Velpeau's,  296 
water  glass,  308 
wax,  308 
Y,-  301,  302 
Bandaging,  286 
rests  in,  287 
position  for,  287 
rules  for,  288 
Baner's    formula    for    modification    of 

milk,  770 
Barley-gruel,  843 
dextrinized,  844 
Barley-jelly,  844 
Barley-meal,  777 
Barley-water,  845 
as  infant  food,  774 
enteroclysis,  169 
Barton's  bandage,  294 
Base,  definition  of,  341 
Basham's  mixture,  349 
Basins  in  operating-room,  544 
Bath,  92 

alkaline,  105 
arm,  99,  100 
bed-,  70 
bran,  105 
Brandt,  100 

hemorrhage  and  perforation  during, 

104 

symp'toms  of  injurious  effect,    102 
cold,  92,  100 

in  nervous  diseases,  104 
in  typhoid  fever,  100 

cyanosis    and    shivering   after, 

103 
hemorrhage     and     perforation 

during,  104 
symptoms  of   injurious  effect, 

102 

constant  immersion,  98,  99 
foot-,  hot,  98 
hot,  92 
foot-,  98 

for  cleansing  purposes,  94 
sitz-,  97 


INDEX 


851 


Bath,  hot,  to  induce  perspiration,  95 
to  relieve  convulsions,  97 

hot-air,  110 

leg,  99,  100 

local,  99 

medicated,  105 

mustard,  105 

rules  for,  93 

salt-water,  104 

sitz-,  hot,  97 

starch,   105 

stimulating,  105 

sulphur,  105 

sweat-,  108 

pilocarpin  in  conjunction  with,  109 

tank,  98 

tub-,  cold,  100.     See  also  Cold  bath. 
hot,  92.     Soe  also  Hot  bath. 
in  bed,  106 
medicated,  105 

turpentine,  106 

Bath-room,  temperature  of,  93 
B.  B.  C.  powder,  460 
Bed,  59 

air-,  82 

arranging  patient  in,  89 

ether,  569 

preparation  of,  for  collapse,  570 

lifting  patient  from,  88 
in,  87 

making  of,  63 

medical,  changing  of,  65 

raising  patient  to  sitting  posture  in, 
88 

returning  patient  to,  89 

surgical,  changing  of,  66,  67 

top  sheet  of,  turning,  without  expos- 
ing patient,  68 

tub-bath  in,  106 

turning  patient  in,  87 

ward,  cleaning  of,  836 

water-,  82 

method  of  placing  patient  on,  82 
Bed-bath,  70 
Bed-clothes,  62 

picking  at,  222 

Bedding,  ward,  cleaning  of,  836 
Bed-making,  59,  63 
Bed-pan,  care  of,  83 

covering  of,  83 

method  of  giving,  82 

Perfection,  83 

varieties  of,  83 

washing  of,  83 
Bed-rest,  89 
Bed-sores,  77 

prevention  of,  77 

treatment  of,  77 
Bedsteads,  wooden,  60 
Beef-juice,  777,  884 

as  infant  food,  774 
Beef-tea,  777,  845 
Belladonna  and  glycerin  stupe,  139 

overdose  of,  treatment,  383 

plaster,   153 

poisoning  by,  treatment,  383 
Beverages,  779 

recipes  for,  845 

starchy,  781 

Bichlorid  of  mercury  as  antiseptic,  454 
MS  vaginal  douche,  174 
stain  on  linen,  removal,  821 

tablets,  455 


Bile,  752,  753 

color  of  urine  from,  272 

in  urine,  283 

Bile-ducts,  obstruction  of,  diet  in,  798 
Bilious  vomiting,  257 
Binder,  299 

abdominal,  300 

breast-,  300 

Y-shaped,  301,  302 
Bismuth   subnitrate   in   vomiting   after 

operations,  575 
Bite  of  animal,  671 

of  rabid  animal,  671 

snake-,  672 
Black  stools,  267 

wash,  350 

Bladder,  condition  of,  after  operations, 
573 

examination  of,  238 

infection  of,   in  catheterization,    185, 
186 

irrigation,  186 
Blanc-mange,  767 
Bland  enema,  166 

enteroclysis,  169 
Blankets,  63 

ward,  822 
Blaud's  pills,  350 
Blebs,  246 

in  syphilis,  730 
Bleeder's  disease,  624 
Blind  boil,  674 
Blister,  149,  246 

fever-,  731 

flying,  151 
Blistering  fluid,  150 
Blood,  altered,  in  vomitus,  257 

bacteria  in,  obtaining  of,  for  culture 
purposes,  527 

casts  in  urine,  276 

color  of  urine  from,  272 

culture,  253,  527 

examination  of,  248 

fresh,  in  vomitus,  257 

in  stools,  265 

in  urine,  276,  280 

in  vomitus,  257 
Blood-corpuscles,  counting,  249 

red,  240 

white,  250 
Blood-count,  249 
Blood-poisoning,  441 
Blood-pressure,  estimation  of,  204,  205 
Blood-red  urine,  272 
Blood-serum,  Loffler's,  as  culture-media, 

405 

Blood-smear,  252 
Blood-stains  on  linen,  removal,  820 

on  scrubbed  wood,  removal,  833 
Bloody  sputum,  261 
Blue  pills,  350 

pus,  440,  656 

stone,  350 

as  antiseptic,  460 

stools,  267 

Blueness  of  skin,  244 
Boards,  fracture,  322 
Boas'  test-meal,  258 
Bodily  strength  as  symptom,  220 
Body,  condition  of,  as  symptom,  220 
Boil,  441,  674 

blind,  674 
Boiling,  disinfection  of  excreta  by,  467 


852 


INDEX 


Boiling,  sterilization  by,  448 

urine,  278 

Boldt's  operating-table,   539 
Bomb  calorimeter,  747 
Bond's  splint,  314 
Bony  union  in  fractures,  630 
Boric  acid  as  antiseptic,  458 
as  ear  douche,  177 
in  pain  after  eye  operations,  585 
vaginal  douche,  174 
Bottger's  test  for  glycosuria,  282 
Bottles,  hot-water,  130 

label  on,  reading,  352 

nursing,  care  of,  773 
Bougie,  esophageal,  689 

rubber,  sterilization  of,  486 

silk,  sterilization  of,  486 
Bouillon,     nutrient,    as    culture-media, 

405 

Bowels,    hemorrhage    from,    266,    614. 
See  also  Enterorrhagia. 

movements,  after  abdominal  section, 

578 

Box-splint,  312 
Brachial  arterv,  digital  compression  of, 

598 

Bradford  frame,  320,  321 
Bradycardia,  207 
Brain,  concussion  of,  697 

operations  on,  sterilization  in,  475 
Bran  bag,  130 

bath,  105 
Brandt  bath,  100 

cyanosis  and  shivering  after,  103 
hemorrhage  and  perforation  during, 

104 

symptoms  of  injurious  effect,  102 
Brandy  enema,  164 
Branny  desquamation,  727 
Brass,  cleaning  of,  834 
Brawny  swellings,  247 
Bread  poultice,   135 
Breaking  down  of  tissue,  247 
Breast,  figure-of-8  bandage  of,  295 

operations  on,  sterilization  in,  474 

Y-shaped  binder,  301 
Breast-binder,  300 
Breath,  odor  of,  as  symptom,  221 
Breathing,  209.     See  also  Respiration. 
Bricks,  hot,  130 
Bromids,  full  doses,  symptoms  of,  386 

in  vomiting  after  operations,  575 
Bromism,  386 
Bronchial  r&les,  225 
Bronzing  of  skin,  245 
Broths,  meat,  777 
Brown  mixture,  349 
Brushes,  hand-,  sterilization  of,  500 
Bubbling  rales,  225 
Bubonic  plague,  infection  by,  416 
Buck's  extension  apparatus,  318 
Burns,  662 

by  electricity,  670 
treatment,  671 

by  lightning,  670 

carron  oil  in,  663,  666 

complications  of,  668 

dressings  for,  666 

embolism  in,  669 

erysipelas  in,  669 

immersion  treatment,  665 

nephritis  in,  669,  670 

of  eye,  treatment,  665 


Burns  of  first   degree,   treatment,   im- 
mediate local,  663 

of   second   degree,   treatment,   imme- 
diate local,  664 

of  third  degree,  treatment,  immediate 
local,  664 

of  throat,  treatment,  665 

open  treatment,  664 

picric  acid  in,  667 

protective  in  dressing  of,  513 

scar  tissure  from,  667 

scarlet  fever  in,  669 

shock  in,  668 

treatment  of,  immediate  local,  663 
immersion,  665 
open,  664 
physical,  667 

vaselin  in,  666 
Buttermilk,  764,  842 
Byrd's  method  of  artificial  respiration, 

695 


CABINET    arranged    for    giving    sweat- 
bath,  112 

Calcium  chlorid  in  enterorrhagia,  615 
in  hemorrhage,  609 

oxalate  in  urine,  diet  for,  801 
Calculus,  urinary,  271 
Callus,  630 

provisional,  630 
Calomel,  349 
Caloric  value  of  food,  746 
Calories,  748 

in  diet,  748 

Calorimeter,  bomb,  747 
Camphor  in  shock,  593 

after  abdominal  section,  581 
Cane-sugar,  effect  of  cooking  on,  761 
Cannulas,  sterilization  of,  481 
Cantharidal  cerate  as  vesicant,  150 

collodion,  150 

ointment  as  vesicant,  150 
Cantharides,  149 

plaster,  150 

Capacity  of  baby's  stomach,  774 
Capeline  bandage,  295 
Capillary  hemorrhage,  595 

pulse,  208 

Capsicum  plaster,  153 
Capsules,  341 
Carbohydrates,  740,  741 

diet  of,  785 

digestion  of,  751 

effect  of  cooking  on,  760 
Carbol-fuchsin  solution,  Ziehl's,  400 
Carbolic  acid  as  antiseptic,  456 
color  of  urine  from,  273 
poisoning,  treatment,  373 
Carbon  dioxid,  739 
Carbonate    of    ammonia    as    emetic    in 

poisoning,  371 
Carbonated  waters,  779 
Carbuncle,  441,  675 
Card  system  in  giving  medicines,  353 
Cardiac  embolism,  659 
Carminative,  definition  of,  341 

enema,  165 
Carotid    arteries,    common,    taking    of 

pulse  at,  202 
Carphology,  222,  703 
Carron  oil,  350 

in  burns,  663,  666 


INDEX 


853 


Carrying  patient  in  operation  in  private 

house,  563 
on  stretcher,  89 
Casein,  764,  768 
Caseinogen,  764 
Castor-oil  enema,  165 
Casts,  bacterial,  in  urine,  276 
blood,  in  urine,  276 
epithelial,  in  urine,  276 
fatty,  in  urine,  276 
granular,  in  urine,  276 
hyaline,  in  urine,  275 
in  urine,  275 
oily,  in  urine,  276 
pus,  in  urine,  276 
waxy,  in  urine,  275 
Catalepsy,  706 
Cataplasm,  131 
Catgut,  490 

chromicized,  493 
cumol,  494 
formalin,  493 
iodized,  492 

plain,  sterilization  of,  492 
sterilization  of,  490 
Catharsis  before  emergency  operations, 

566 

before  operation,  565 
Cathartic,  definition  of,  342 
time  of  administering,  346 
Catheter,   182 
double,  186 
Eustachian,  243 
filiform,  sterilization  of,  486 
glass,   182 

sterilization  of,  486 
guarded,  187 

metal,  sterilization  of,  486 
rubber,   182 

sterilization  of,  485 
silver,  sterilization  of,  481 
Catheterization,  182 
after  operations,  573 
cystitis  in,  186 
in  male,  187 

infection  of  bladder  in,  185,   186 
of  ureters,  238 
position  of  patient,   183 
Caustics,  152 
Cauterization,  147 

sterilization  in,  477 
Cautery,  actual,  as  counterirritant,  147 

in  hemorrhage,  607 
Paquelin,  147,  148 
in  operations,  553 
sterilization  of,  481 
Cavities,  illumination  of,  239 

packing  of,  512 
C'ellulitis,  657 
Cellulose,  741 
Centigrade  thermometer,  200 

converting  to  Fahrenheit  scale,  200 
Centimeter,  335 

abbreviation  for,  337 
cubic,  abbreviation  for,  337 
Central  preparatory  schools  for  nurses, 

48 

vomit  ing,  713 
Centrifuge,  275 
Cereals,  776 

cooking  of,  761 
Cerebral  concussion,  697 
embolism,  659 


Cerebral  hemorrhage,  623 

shock,  697 

Cerium  oxalate  in  vomiting  after  opera- 
tions, 575 
Cervix  dilators,  237 

operations  on,  sterilization  in,  475 
Cestodes,  395 
Chafing,  733 
Character  of  nurse,  32 
Charcoal  poultice,  135 
Charts,  216,  815 
clinical,  216 
special,  218 
temperature,  216 

in  intermittent  malaria,  198 
of  lobar  pneumonia,  197 
of  typhoid  fever,  198 
Chemical  antidote,  369 
composition  of  food,  738 

of  milk,  763 

compound,  definition,  341 
disinfection  of  excreta,  467 
examination  of  urine,  276 
sterilization,  454 
Chemotaxis,  negative,  390 

positive,  390 

Chest,  diminished  expansion  of,  214 
examination  of,  226 

in  children,  226 
handkerchief  bandage  of,  303 
Chest-wall,  aspiration  of,  535 
Cheyne-Stokes  respiration,  213 
Chicken-pox,  nursing  in,  437 

rash  in,  727 
Chjcken-tea,  777,  845 
Childbirth,  hemorrhage  connected  with, 

620 

Chill,  719 

China,  sterilization  of,  487 
Chloral,  overdose  of,  treatment,  383 

poisoning  by,  treatment,  383 
Chlprin  as  antiseptic,  461 
disinfection  of  room,  466 
in  urine,  271 
Chlorinated  lime  as  antiseptic,  462 

soda  as  antiseptic,  462 
Chloroform  anesthesia,  359 

as  vesicant,  151 

Chloroform-inhaler,  Esmarch's,  359 
Chlorophyl,  388 
Chlorosis,  color  of  skin  in,  245 
Chocolate,  781 

Baker's  powdered,  846 
Cholagpgue,  definition  of,  342 
Chromicized  catgut,  493 
Chromogenic  bacteria,  390 
Chyle  in  urine,  282 
Chyluria,  282,  283 
Chyme,  752 
Cinchonism,  386    . 
Clabber,  841 

Clavicle,    fracture    of,    adhesive    strap- 
ping in,  325 

Sayre's  dressing  in,  325,  326 
treatment,  637 

immediate,  633 

Clean  nurse,  502.     See  also  Sterile  ?n/rse. 
Cleaning  and  dusting  of  ward,  807 
Cleansing  accidental  wounds,  651 
bath,  94 

patient  before  operation,  567 
Clinical  charts,  216 
thermometer,  200 


854 


INDEX 


Clonic  convulsion,  677 

Closet  for  instruments,  482 

Clothes,  bed-,  62 

Clothing,  removal  of,  in  fracture,  633 

Cloudy  urine,  277 

Clove-hitch  knot,  329 

Clover  inhaler,  360 

Clyster,  155.     See  also  Enema. 

Coaptation  splinting,  Gooch's,  318 

Cocain  hydrochlorid  in  vomiting  after 

operations,  575 
poisoning  by,  treatment,  384 

hypodermic    injection    of,    as    local 

anesthetic,  354 
Cocci,  390,  392 
Cocoa,  781,  846 
Coddled  egg,  842 
Coffee,  780 

enema,  163 

stains  on  linen,  removal,  821 
Coffee-ground  vomitus,  257 
Coils,  ice-,  126 

Letter's,  126 
Coin-catcher,  688,  689 
Cold  affusion,  115 

applications,  113,  123 

bath,  92,  100 

in  nervous  diseases,  104 
in  typhoid  fever,  100 

cyanosis    and    shivering    after, 

103 
hemorrhage     and     perforation 

during,  104 

symptoms  of  injurious  effect, 
102 

dry,  application  of,  125 

exposure  to,  673 

in  epistaxis,  618 

in  fractures,  635 

in  hemorrhage,  608 

in  inflammation,  121 

in  subcutaneous  hemorrhage,  613 

moist,  application  of,  123 

pack,  117 

sore,  731 

sponge,  113 

water  in  hemorrhage,  608 
Cold-water  coils,  126 
Collagen,  491 
Collapse,  194,  196,  592 

algid,  194 

dosage  in,  344 

preparation  of  ether  bed  for,  570 
Colles'  fracture,  treatment,  636 
Collodion,  cantharidal,  150 

dressing,  513 

styptic,  in  hemorrhage,  608 
Colon,  flushing  of,  170 
Colony,  404 
Coma,  705 

diabetic,  705 

vigil,  705 

Combustion,  739.  746 
Comma  spirilla,  393 
Commercial  valuation  of  nursing,  38 
Coiaminuted  fractures,  628 
Common    carotid    arteries,     taking    of 

pulse  at,  202 
Compound  asafetida  enema,  165 

purgative  enema,  165 
Compress,  hot,  140 

ice,  123 
Compressible  pulse,  205 


Compression  in  hemorrhage,  598.      See 

also  Pressure. 

Concealed   hemorrhage,   595,   613,   614. 
Concussion,  cerebral,  697 
Condenser,  Abbe\  397 
Condiments,  744 
Cone,  ether,  361,  362 
Constipation,  716 

acute,  716 

chronic,  716 
diet  in,  799 

consistence  of  stools  in,  264, 

massage  in,  717 

symptoms  of,   physical,   716 

treatment  of,  716 
Contagious  diseases,  408 
Continued  fever,  724 
Continuous  fever,  197 

rectal  infusion,  170 
Contused  wound,  treatment,  654 
Contusion,  649 
Convalescence  in  fever,  724 
Convulsions,  222,  677 

clonic,  677 

continuous,  677 

epileptiform,  677 

general,  677 

hot  bath  to  relieve,  97 

in  alcoholism,  679 
treatment,  680 

in  children,  682 

in  epilepsy,  679 

in  hysteria,  684 

in  spinal  meningitis,  683 

in  strychnin-poisoning,  683 

in  tetanus,  678,  683 

in  tetany,  677,  678,  681,  684 

in  uremia,  679 
treatment,  681 

intermittent,  677 

local,  677 

tetanic,  677,  678 

tonic,  677 

treatment  of,  678 
Cooking,  737,  758 

effect  of,  on  carbohydrates,  760 
on  fats,  761 
on  proteins,  760 

of  cereals,  761 

of  vegetables,  761 
Copper,  cleaning  of,  834 

sulphate  as  antiseptic,  460 

test  for  glycosuria,  282 
Corn,  ground,  poultice  of,  135 
Corpuscles,  blood-,  counting  of,  249 
Correspondence  training-schools,  11 
Corrigan's  pulse,  208 
Corrosive  poisons,  371,  372 
table  of,  374 

sublimate  as  disinfectant,  454 
Corrosives,  poisoning  by,  372 
convalescence  from,  373 
symptoms,  372 
treatment,  372 
Cotton  jacket,  130 

mattress,  60 

styptic,  in  hemorrhage,  608 
Counterirritants,  140 
Counterirritation  in  inflammation,  122 
Counting  sponges  in  operations,  553 
Cover-glass.  398 
Cowpox,  infection  by,  416 
Cracker-gruel,  843 


INDEX 


855 


Crackling  rales,  225 
Cradle,  Sautter's,  323 
Cradles,  323 

ice-,  116 
Cream,  764 

of  tartar,  349 
Creatinin  in  urine,  271 
Creolin  as  antiseptic,  457 
Crepitant  rales,  225 
Crinolin  bandages,  286,  287 
Crisis,  196,  422 

of  fever,  724 

unusual,  222 

Crockery,  kitchen,  cleaning  of,  834 
Croton  oil  as  vesicant,  152 
Croup  kettle,  111,  366 

tent,  367 

Crowing  respiration,  212 
Crude  drug,  mixing  solutions  from,  470 
Crusts,  727 

Crutches  on  operating-table,  540 
Crystalline  lens,  240 
Crystals  in  urine,  276 
Cube,  definition  of,  335 
Cubic  centimeter,  abbreviation  for,  337 
Culture,  blood-,  253,  527 

from  sterilized  articles,  500 

of  bacteria,  402 

instruments  for  making,  404 

smear-,  398 

taking  of,  406 

pure,  404 
Culture-media,  402 

agar-agar,  405 

Loffier's  blood-serum,  405 

milk,  405 

nutrient  bouillon,  405 

raw  potato,  405 
Cumol  catgut,  494 
Cupboards  in  operating-room,  543 
Cupful,  apothecaries'  equivalent,  334 
Cupping,  dry,  142 

wet,  144 

sterilization  in,  477 
Cups,  sputum-,  262 
Curds  of  milk,  765 
Cutaneous  emphvsema,  248 
Cyanosis,  215,  244 

after  Brandt  bath,  103 
Cycle,  Koch's,  410,  411 
Cystitis  from  catheterization,  186 
Cysts,  395 

hydatid,  395 


DATURIN,  poisoning  by,  treatment,  385 

Death-rattle,  224 

Decay,  389 

Deep  respiration,  211,  212 

Deliriants,  704 

Delirium,  703 

low  muttering,  703 

tremens,  704 

wild,  703 
Delusion,  704 
Density  of  urine,  271 
Deodorants,  454 
Depressed  fractures,  628 
Desquamation,  727 

branny,  727 

flaky,  727 
Dessertspoon,  apothecaries'  equivalent, 

334 


Dextrin,  741 

Dextrinized  barley-gruel,  844 

flour  with  buttermilk,  844 
Dextrose,  742,  752,  761 

in  urine,  282.     See  also  Glycosuria. 
Diabetes  mellitus,  diet  in,  801 
Diabetic  coma,  705 
Diachylon  plaster,  153 
Diaphoresis,  196,  720 
Diaphoretic,  definition  of,  342 
Diaphoretics,  721 
Diaphysis,  fracture  at,  626 
Diarrhea,  717 

acute,  717 
diet  in,  795 

chronic,  718 

consistence  of  stools  in,  264 

in  infancy,  718 
diet  in,  795 

symptoms  of,  physical,  718 

treatment  of,  718 
Diazo-reaction,    Ehrlich's,    in    typhoid 

fever,  284 
Dicrotic  pulse,  208 
Diet,  782 

after  abdominal  section,  576,  577 

before  operation,  566 

calories  in,  748 

carbohydrates,  785 

eggs,  784 

fat,  785 

fish,  784 

general  division  of,  782 

high  caloric,  749 

in  acute  diarrhea,  795 
digestive  disorders,  794 
dysentery,  795 
gastric  disorders,  793,  794 
intestinal  disorders,  793,  794 

in  anemia,  803 

in  chronic  constipation,  799 
digestive  disorders,  796 
gastric  disorders,  793,  796 
intestinal  disorders,  793,  796 

in  constipation,  799 

in  diabetes  mellitus,  801 

in  diarrhea,  794 
in  infancy,  795 

in  dilatation  of  stomach,  798 

in  diseases,  787 
of  intestines,  792 
of  stomach,  792 

in  dropsy,  800 

in  duodena!  ulcer,  794 

in  dysentery,  795 

in  fevers,  788 

in  gastric  disorders,  792 
ulcer,  794 

in  glycosuria,  801 

in  inflammation  of  kidneys,  799 

in  intestinal  disorders,  792 

in  nephritis,  799 

in  obstruction  of  bile-ducts,  798 

in  oxaluria,  801 

in  phthisis,  802 

in  rickets,  803 

jn  scurvy,  803 

in  tuberculosis,  802 

in  typhoid  fever,  789 

liquid,  782 

low  caloric,  750 

meat,  784 

milk,  feces  of,  264 


856 


INDEX 


Diet,  points  for,  786 

vegetable,  785 
Dieting,  782 
Diet-sheets,  ward,  815 
Digestibility  of  food,  751 
Digestion,  751 

conditions  disturbing,  756 

mechanical  aids  to,  754 

of  carbohydrates,  751 

of  fats,  752 

of  proteins,  751 

time  for,  756 

Digestive  disorders,  acute,  diet  in,  794 
chronic,  diet  in,  796 

juices,  752 

stimulation  of,  754 
Digestives,  time  of  administering,  345 
Digital  pressure  in  hemorrhage,  603 
of  brachial  artery,  598 
of  femoral  artery,  602 
Digitalin,   hypodermic  injection,   356 
Digitaline,  hypodermic  injection,  356 
Digitalis  in  hemorrhage,  611 

in  shock  after  abdominal  section,  581 

overdose  of,  treatment,  384 

poisoning  by,  treatment,  384 

poultice,  136 

stupe,  139 

Dilatation  of  stomach,  diet  in,  798 
Dilators,  cervix,  237 
Diphtheria  antitoxin,  425 

nursing  in,  434 
Diplococci,  390,  391,  392 
Disease,  gradual  onset,  197 

sudden  onset,  197 

Disinfectants,  454.     See  also  Antiseptics. 
Disinfection,  chemical,  of  excreta,  467 

of  excreta,  466 
by  boiling,  467 
in  country  districts,  467 

of  feces,  467 

of  linen,  821 

of  room,  464 
chlorin,  466 
formaldehyd  for,  464 
preparation  for,  466 
sulphur,  465 

of  vessel  containing  infectious  stool, 

467 
Dislocation,  645 

closed,  645 

complicated,  645 

compound,  645,  646 

of  finger,  treatment,  647 

of  lower  jaw,  treatment,  647 

open,  645 

reduction  of,  645 

simple,  645 

symptoms  of,  645 

varieties,  645 
Distention  of  intestine  after  abdominal 

section,  579 
Diuresis,  196.  273 
Diuretic,  273 

definition  of,  342 
Domestic  training  of  nurse,  53 

work,  ward,  827 
Dorsal  position,  229 

recumbent  position,  229 
Dosage,  342 

in  children,  342 

in  collapse,  344 

in  shock,  344 


Dosage,  influence  of  age  on,  342 
of  fasting  on,  343 
of  idiosyncrasy  on,  343 
of  individuality  on,  343 
of  pain  on,  344 
of  race  on,  343 
of  sex  on,  343 
of  antidote  drug,  344 
of  aquse,  346 
of  dilute  acids,  347 
of  fluidextracts,  346 
of  infusions,  346 
of  mixtures,  347 
of  spirits,  346 
of  syrups,  346 
of  tinctures,  346 
Young's  rule,  342 
Doses,  fractional,  333 
Double  catheter,  186 
inclined  plane,  318 
Douche,  172 

A.  B.  C.  antiseptic,  174,  463 
ear,  177 

boric  acid,  177 
eye,  178 

of  infant,  180 
intra-uterine,  174 
nasal,  176 
vaginal,  172 

bichlorid  of  mercury,  174 
boric  acid,  174 
position  of  patient  in,  173 
Dover's  powder,  349 
Down  pillow,  61 
Drainage  after  abdominal  section,  577 

of  incised  wound,  653 
Dram,  abbreviation  for,  331 
Draw-sheets,  62,  63 
Dress,  patient's,  in  operating-room,  546 
Dressings,  application  of,  513 
collodion,  513 
for  burns,  666 
sterilization  of,  496 
surgical,  509 
Drink,  imperial,  845 
Drop,  332 

Droplet  infection,  413 
Dropsy,  247,  711 
diet  in,  800 
in  anemia,  712 
in  heart-disease,  712 
in  nephritis,  711 

of  abdomen,  paracentesis  in,  529 
overdosing  in,  344 
treatment  of,  712 

Drowning,  artificial  respiration  in,  692 
Drugs,  accumulation  of,  in  system,  344 
acting  locally  on  stomach,  time  to  ad- 
minister, 345 
action    of,    circumstances    modifying, 

343 

administration  of,  350 
by  fumigation,  368 
by  inha|ation,  358 

for  stimulation,  364 
by  inunction,  368 
by  mouth,  351 
by  rectum,  353 

hypodermic,  354.      See  also  Hypo- 
dermic injection. 
classification  of,  338-340 
crude,  mixing  solutions  from,  470 
dosage  of,  342.     See  also  Dosage. 


INDEX 


857 


Drugs  for  hypodermic  injection,  355 

fractional  doses  of,  333 

injury  to  teeth  from,  352 

irritating,  time  of  administering,  346 

names  of,  338-240 

odor  of  urine  .from,  273 

physiologic  limit,  369 

time  of  administration,  345 
required  for  effect,  344 

tolerance  to,  344 

volatile,  action  of,  344 

with  specific  action  in  infectious  dis- 
eases, 432 

Drumstick  bacilli,  390,  392 
Dry  cold,  application  of,  125 

cupping,  142 

gangrene,  658 

heat,  application  of,  128 
sterilization  by,  448 

rales,  225 

Duodenal  ulcer,  diet  in,  794 
Dupuytren's  splint,  316 
Dusting  and  cleaning  of  ward,  807 

ward,  830 

Dusting-powders,  sterilization  of,  495 
Dysentery,  acute,  diet  in,  795 
Dyspnea,  212 


EAR  douche,  177 
boric  acid,  177 

examination  of,  241 

foreign  bodies  in,  removal  of,  686 

hemorrhage  from,  620 

operation  on,  sterilization  in,  476 
Ear-drum,  241 
Earth-worm,  396 

in  stools,  268 
Ecbolic,  definition  of,  342 
Ecchymosis,  247,  613 
Eclampsia,  682 
Ecstasy,  706 
Eczema,  papular,  733 

pustulous,  733      . 

rash  in,  733 

squamous,  733 
Edema,  247,  711 
Education  of  nurse,  33 
Eggnog,  843 

with  coffee,  tea,  or  cocoa,  843 
Eggs,  775 

coddled,  842 

diet  of,  784 

hard-boiled,  842 

poached,  842 

recipes  for,  842 

scrambled,  842 

shirred,  842 

soft-boiled,  842 

Ehrlich's  diazo-reaction  in  typhoid  fever, 
284 

theory  of  immunity,  428 
Elbow,  forced  flexion  of,  599 
Electricity,  burns  by,  670 
treatment,  671 

in  shock,  593 

Element,  definition  of,  341 
Elephantiasis,  248,  395 
Elixir  iron,  quinin,  and  strychnin,  349 
Embolism,  659 

cardiac,  659 

cerebral,  659 

in  burns,  669 


Embolism,  pulmonary,  659 

traumatic,  659 
Embolus,  659 
Emergencies,  592 
Emergency  operations,  catharsis  before, 

566 
duties  of  nurse  in,  553 

table,  542 
Emesis,  712 

Emetic,  definition  of,  342 
Emetics,  712 

in  poisoning,  370 
Emmenagogue,  definition  of,  342 
Emollient  enema,  166 
Emphysema,  cutaneous,  248 
Emplastrum,  153 
Enamel  ironware,  cleaning  of,  831 
Enamelware,  sterilization  of,  487 
Enema,  155 

alum,  165 

asafetida,  165 
compound,  165 

astringent,  166 

avoidance  of  injecting  air,  157 

bland,  166 

brandy,  164 

carminative,  165 

castor-oil,  165 

coffee,  163 

compound  asafetida,  165 
purgative,  165 

emollient,  166 

gelatin,  165 

glycerin,  164 

high,  159 

in  infant,  160 

low,  159 

medicated,  164 
purgative,  164 

nutritive,  162 

oil,  164 

position  of  patient,  158 

quantity  given  by,  160 

quassia,  166 

rectal  tubes  for,  156 

salt  solution,  161,  163 

salts,  164 

simple,  161 

soapsuds,  161 

starch,  166 

stimulating,  163 

temperature  of,  160 

turpentine,  165 

whisky,  164 
Energy,  741,  742,  746 

potential,  of  food,  748 
Enteroclysis,  167 

astringent,  167 

barley-water,  169 

bland,  169 

flaxseed,  169 

gruels,  169 

nitrate  of  silver,  169 

salt  solution,  168 

tannic  acid,  169 
Enterorrhagia,  614 

calcium  chlorid  in,  615 

ergot  in,  615 

from  hemorrhoids,  treatment,  616 

gelatin  in,  615 

hypodermoclysis  in,  615 

morphin  in,  615 

salt  solution  in,  615 


858 


INDEX 


Enterorrhagia,  symptoms  of,  615 

tarry  stools  after,  615 

treatment  of,  615 
Enzymes,  407,  752 
Eosinophiles,  251 
Epjlepsy,  convulsions  in,  679 
Epileptiform  convulsions,  677 
Epiphysis,  fracture  at,  626 
Epispastic,  140,  149 

definition  of,  342 
Epistaxis,  617 

adrenalin  chlorid  in,  619 

cold  in,  618 

in  purpura,  618 

in  scurvy,  618 

iron  in,  619 

plugging  pares  in,  619 

tannic  acid  in,  619 
Epithelial  casts  in  urine,  276 
Epithelium,  bacteria  in,  414 
Epsom  salts,  350 
Ergot  in  enterorrhagia,  615 

in  hemorrhage,  609 

in  postpartum  hemorrhage,  621 
Ergotin  in  hemorrhage,  609 

in  postpartum  hemorrhage,  621 
Eruptive  fevers,  727 
Erysipelas  from  wounds,  660 

idiopathic,  660 

in  burns,  669 

nursing  in,  438 

rash  in,  730 

traumatic,  661 
Erythema,  245 

intertrigo,  733 

nodosum,  732 

simplex,  732 

Erythematous  rash,  245,  731 
Erythrocytes,  250 
Esbach's  albuminometer,  279,  280 
Escharotics,  140,  152 
Eserin  in  intestinal  distention  after  ab- 
dominal section,  580 
Esmarch  bandage,  rubber,  287 

chloroform-inhaler,  359 
Esophageal  bougie,  689 

forceps,  689 

Esophagus,  foreign  bodies  in,  688 
Ether  anesthesia,  360,  568 
closed  method,  361 
open  method,  362 
primary,  362 
profound,  363 
semi-open  method,  362 
stages,  362 
surgical,  363 

bed,  569 

preparation  of,  for  collapse,  570 

cone,  361,  362 

for  removing    fat    and    grease    from 
skin,  459 

in  shock,  593 

inhaler,  Clover,  360 
Etherization,  568 
Ethyl  bromid  anesthesia,  364 

chlorid  anesthesia,  364 
Eucain,    hypodermic    injection    of,    as 

local  anesthetic,  354 
Eustachian  catheter,  243 

tubes,  Politzer's  bag  for  dilating,  244 
Evacuations,  involuntary,  222 
Eversion  in  Pott's  fracture,  636 
Ewald's  test-meal,  258 


Exanthematous  fevers,  727 
Excreta,  264 
condition  of,  84 
disinfection  of,  466 
by  boiling,  467 
chemical,  467 
in  country  districts,  467 
Exhaustion,  heat,  698 

theory  of  immunity,  427 
Expansion,  diminished,  of  chest,  214 
Expectorant,  definition  of,  342 
Exploration,  523 
Exploratory   puncture   of   pericardium, 

524 

Exposure  to  cold,  673 
Extension,  318 

apparatus,  Buck's,  318 
treatment  of  fractures,  635 
vertical,  321 
Extractives,  741 
Extracts,  meat,  777 
Eye,  appearance  of,  as  symptom,  221 
bandage  of,  293 
burns  of,  treatment,  665 
douche,  178 

of  infant,  180 
effect  of  atropin  on,  240 
of  homatropin  on,  241 
examination  of,  239 
figure-of-8  bandage  of,  293,  294 
foreign  bodies  in,  removal  of,  685 
operations  on,  584 
care  after,  585 
pain  after,  585 
sterilization  in,  476 


FACIAL  artery,  compression  of,  603 
taking  of,  pulse  at,  202 

expression  as  symptom,  221 

paralysis,  711 
Facultative  bacteria,  389 
Fahrenheit  thermometer,  200 

converting  to  Centigrade  scale,  200 
Fainting,  696 

treatment  of,  697 
Fallopian   tube,    ruptured,    hemorrhage 

from,  622 

Familiar  preparations,  349 
Fastigium,  723 

of  fever,  199,  432 

Fasting,  influence  of,  on  dosage,  343 
Fat,  740,  742 

diet  of,  785 

digestion  of,  752 

effect  of  cooking  on,  761 

in  feces,  266 
Fat-free  milk,  764 
Fatty  casts  in  urine,  276 
Favus,  735 
Feather  mattress,  60 

pillow,  61 
Fecal  stains  on  linen,  removal,  820 

vomitus,  258 
Feces,  264,  754 

bacteria  in,  269 

in  typhoid  fever,  269 

blood  in,  265 

blue,  267 

color  of,  267 
absence,  267 
black,  267 

consistence  of,  in  constipation,  264 


IXDEX 


859 


Feces,  consistence  of,  in  diarrhea,  264 
disinfection  of,  467 
by  boiling,  467 
chemical,  467 
earth-worm  in,  268 
examination  of,  269 
fat  in,  26fi 

foreign  bodies  in,  268 
gall-stones  in,  268 
green,  267 
greenish-yellow,  267 
in  infancy,  264 
melanotic,  267 
mucus  in,  265 
normal,  264 
odor  of,  266 
of  milk  diet,  264 
parasites  in,  268 
poisons  in,  268 

preparation  of,  for  examination,  260 
pus  in,  266 
red,  267 

seat-worms  in,  268 
tape- worms  in,  268 
tarry,  266,  267 

after  enterorrhagia,  615 
undigested,  264 
watery,  265 
worms  in,  268 
Feeding  by  nasal  tube,  192 
forced,   192 

infant,  768.      See  also  Infant  feeding. 
nasal,  192 

Fehling's  test  for  glycosuria,  282 
Fellow's  syrup,  349 
Felon,  675 

treatment  of,  676 
Felt,  poroplastic,  318 
Femoral  artery,  digital  compression  of, 

602 

taking  pulse  at,  202 
Femur,    fracture   of,    treatment,    imme- 
diate, 632 

Fermentation  of  milk,  766 
Ferments,  752 
Fetid  sputum,  262 
Fever,  194,  722 

Brandt  bath  in,  100 

causes  of,  722 

continuous,  197,  724 

convalescence  in,  724 

course  of,  723 

crisis  of,  196,  724 

decline  of,  432,  724 

diet  in,  788 

duration  of  periods,  725,  726 

eruptive,  727 

exanthematous,  727 

fastigium  of,  199,  432,  723 

gradual  onset,  197 

hectic,  199,  725 

in  phthisis,  199 
incubation  period,  725 
infectious,  722 
intermittent,  197,  724 
invasion  period,  199,  723 
abrupt,  724 
gradual,  724 
irregular,  725 
lysis  of,  196,  724 
onset  of,  199,  723 
prodromes  of,  723 
remissions  of  temperature  in,  724 


Fever,  remittent,  197,  724 
stadium  of,  199,  723 
sudden  onset,  197 
symptoms  of,  physical,  723 
Fibrous  union  of  fractures,  631 
Fever-blister,  731 
Field  tourniquet,  605 

application  of,  605 
Figure-of-8  bandage,  290 
of  both  shoulders,  290 
of  breast,  295 
of  eye,  293,  294 
of  foot,  291 
of  hand,  292 
of  instep,  291 
of  jaw,  294 
of  nape  of  neck,  295 
posterior,  290 

Filaria  sanguinis  hominis,  395 
Filiform  catheters,  sterilization  of,  486 
Fingers,  bandage  of,  292 

dislocation  of,  treatment,  647 
Fish,  diet  of,  784 
Fishing-gut,  487 
Fission  of  bacteria,  388,  393 
Fistula,  658 
Fits,  677 
Flagellae,  393 
Flaky  desquamation,  727 
Flame,  actual,  sterilization  by,  448 
Flavoring  milk,  767 
Flaxseed  enteroclysis,  169 
poultice,  131 

addition  of  glycerin  and  belladonna 

to,  135 

addition  of  opium  to,  135 
Flaxseed-tea,  846 
Fleischl's  hemoglobinometer,  253 
Flexion,  forced,  of  elbow,  599 

of  knee,  601 

Flics  as  carriers  of  disease,  417 
Floors,  mopping  of,  in  ward,  828 
polishing  of,  in  ward,  829 
protection  of,  in  operations  in  private 

houses,  561 

scrubbing  of,  in  ward,  828 
sweeping  of,  in  ward,  828 
Flour,  dextrinized,  with  buttermilk,  844 
Flour-gruel,  844 
Fluidextracts,  dosage  of,  346 
Flushing  of  colon,  170 
Flying  blister,  151 
Fomentation,  137.     See  also  Stupe. 
Fomites,  413 
Food,  737 

absorption  of,  755 
caloric  value,  746 
chemical  composition,  738 
classification  of,  739 
cooking  of,  737,  738.  See  also  Cooking. 
digestibility  of,  751 
nitrogenous,  741 
of  bacteria,  389 
potential  energy,  748 
preparation  of,  758 
proper  care  of,  in  prevention  of  infec- 
tion, 418 

Foot,  figure-of-8  bandage  of,  291 
handkerchief  bandage  of,  303 
Foot-bath,  hot,  98 
Foot-sling,  90 
Forced  feeding,  192 
Forceps,  esophageal,  689 


860 


INDEX 


Forcible  vomiting,  257 
Forearm,    fracture    of,    treatment,    im- 
mediate, 632 

Foreign  bodies  in  ear,  removal  of,  686 
in  esophagus,  688 
in  eye,  removal  of,  685 
in  feces,  268 
in  larynx,  689 
in  nose,  removal  of,  687 
in  throat,  removal  of,  687 
in  trachea,  689 
removal  of,  685 

Formaldehyd  as  antiseptic,  462 
disinfection  of  room,  464 
fumigator,  464 
Formalin  as  antiseptic,  462 

catgut,  493 
Four-tailed  bandage,  298,  302 

of  jaw,  298 
Fowler's  solution,  349 

test  for  urea  in  urine,  284 
Foxglove  poultice,  136 
Fractional  doses,  333 

sterilization,  453 
Fracture,  626 

ankylosis  from,  627 
at  diaphysis,  626 
at  epiphysis,  626 
boards,  322 
callus  in,  630 
causes  of,  626 
classification  of,  627 
closed,  627 
cold  in,  635 
Colles',  treatment,  636 
comminuted,  628 
complicated,  628 
complications  from,  631 
compound,  627 

treatment,  immediate,  633 
depressed,  628 
extension  treatment,  635 
extracapsular,  627 
from  muscular  contraction,  626 
from  violence,  direct,  626 

indirect,  626 
greenstick,  627 
impacted,  628 
intracapsular,  627 
longitudinal,  626 
massage  in,  635 
multiple,  628 
oblique,  626 

of  clavicle,  adhesive  strapping  in,  325 
Sayre's  dressing  in,  325,  326 
treatment,  637 

immediate,  633 

of  femur,  treatment,  immediate,  632 
of  forearm,  treatment,  immediate,  632 
of  knee,  treatment,  637 
of  leg,  treatment,  immediate,  632 
of  lower  jaw,  treatment,  641 
of  orbit,  treatment,  641 
of  patella,  treatment,  637 
of  pelvis,  treatment,  641 

immediate,  634 

of  ribs,  adhesive  strapping  in,  32i 
complications  from,  638 
treatment,  638 

immediate,  633 

of  skull,  of  base,  treatment,  640 
of  vault,  complications  from,  640 
treatment,  639 


Fracture  of  skull,  treatment,  638 
immediate,  633,  634 

of  spine,  treatment,  643 
immediate,  634 

of  upper  arm,  treatment,  immediate, 
632 

open,  627 

Pott's,  treatment,  636 

removal  of  clothing  in,  633 

repair  of,  629 

simple,  627 

splints  in,  634 

symptoms  of,  627,  629 

transverse,  626 

treatment  of,  631 
extension,  635 
immediate,  631 
surgical,  634 

union  of,  629 
bony,  630 
delayed,  631 
fibrous,  631 

varieties  of,  626 
Frame,  Bradford,  320,  321 
Freckles,  246 
Fremitus,  224 

friction,  224 
French  method,  141 
Friar's  balsam,  350 
Friction  fremitus,  224 
Friction-sounds,  224,  225 
Frost-bite,  673 
Fructose,  742 

Fruit-stains  on  linen,  removal,  821 
Fruit-sugar,  742 

Fumigation,  administering  drugs  by,  368 
Function,    interference    with,    from    in- 
flammation, 120 
Functional  poisons,  372,  381 
Fungi,  388 
Fiirbringer's  method  of  sterilization  of 

hands,  472 
Furniture  inventory,  817 

of  operating-room,  537 

polished,  care  of,  832 
Furuncle,  674 


GABBETT'S  solution,  400 

stain  for  tubercle  bacillus,  400 
Gait  as  symptom,  221 
Galactagpgue,  definition  of,  342 
Gallic  acid  in  hemorrhage,  609 
Gallon,  abbreviation  for,  331 
Gall-stones  in  feces,  268 
Gallows,  306 
Gangrene,  80,  658 

dry,  658 

moist,  658 

traumatic,  658 

treatment  of,  658 
Gangrenous  sputum,  262 
Gastric  disorders,  acute,  diet  in,  793,  794 
chronic,  diet  in,  793,  796 
diet  in,  792 

juice,  752 
acidity,  259 

ulcer,  diet  in,  794 
Gauze  bandages,  287 

iodoform,  498 

sterilization  of,  498 

medicated,  497 

sterilization  of,  499 


INDEX 


861 


Gavage,  192 
Gelatin  enema,  166 

in  enterorrhagia,  615 

in  hemorrhage,  609 
Gelatinoids,  741 

effect  of  cooking  on,  760 
Genupectoral  position,  231 
German  measles,  nursing  in,  437 

rash  in,  729 
Germicides,  454 
Germs,  388 
Ginger-tea,  846 
Glanders,  infection  by,  416 
Glands  of  axilla,  operations  on,  steriliza- 
tion in,  475 

of  neck,  operations  on,  sterilization  in, 

475 
Glass  catheter,  182 

sterilization  of,  486 

cleaning  of,  in  ward,  831 

sterilization  of,  487 
Glauber's  salts,  350 
Gloves,  rubber,  sterilization  of,  484 
Glucose,  742 
Glycerin  enema,  164 

sterilization  of,  496 

suppository,   171 
Glycogen,  741 
Glycosuria,  282 

Bottger's  test  for,  282 

copper  test  for,  282 

diet  in,  801 

Fehling's  test  for,  282 

quantitative  test  for,  283 

Trommer's  test  for,  282 
Gonorrhea,  infection  by,  419 
Gooch's  coaptation  splinting,  318 
Goose-flesh,  721 
Goulard's  extract,  350 
Gowns  in  operating-room,  546 

in  operations  in  private  houses,  562 
Gramme,  gram,  337 

abbreviation  for,  337 
Granny  knot,  327,  328 
Granular  casts  in  urine,  276 
Granulation,  649,  650 

indolent,  650 

redundant,  650 
Grape-sugar  in  urine,  282,  742.    See  also 

Glycosuria. 
Gravel  in  urine,  283 
Gray  powder,  349 
Grease  stains  on  linen,  removal,  821 

on  scrubbed  wood,  removal,  833 
Green  sickness,  color  of  skin  in,  245 

stools,  267 

Greenish-yellow  stools,  267 
Greenstick  fracture,  627 
Gregory  powder,  349 
Groin,  spica  of,  291 
Gruels,  776 

apple,  844 

as  infant  food,  774 

barley,  843 

cracker,  843 

enteroclysis,  169 

flour,  844 

oatmeal,  843 

recipes  for,  843 

rice,  843 

rice-flour,  843 
Grunting  respiration,  212 
Guaiacol  and  glycerin  as  vesicant,  151 


Guarded  catheter,  187 
Gummatous  nodules  in  syphilis,  730 
Gums,  condition  of,  as  symptom,  221 
Gunshot  wounds,  655 
tetanus  from,  655 
Gurgling  rales,  225 
Gutta,  332 


HAIR,  care  of,  84 
mattress,  61 
pediculi  in,  examination  for,  86 

treatment,  86 
pillow,  61 
washing  of,  84 
Hall's  method  of  artificial   respiration, 

691 

Hallucination,  705 
Hand,  figure-of-8  bandage  of,  292 

handkerchief  bandage  of,  303 
Hand-brushes,  sterilization  of,  500 
Handkerchief  bandage,  301.       See  also 

Bandage,  handkerchief. 
Hands,  cleaning  of,  507,  508 

sterilization  of,  471.    See  also  Steriliza- 
tion of  hands. 

Hanging-drop  method  of  examining  bac- 
teria, 401 

Haptophore,  428,  429 
Hard  pulse,  205 
Hard-boiled  eggs,  842 
Harrington's    alcoholic    solution    of    bi- 

chlorid  of  mercury,  463 
iodin  solution,  463 
Hay  bacillus,  393 
Head,  bandage  of,  295 

recurrent,  296 

handkerchief  bandage  of,  302 
nurse,  805 

special  duties,  824 
visiting  rounds,  838 
pediculi  in,  examination  for,  86 

treatment,  86 
support  of,  by  hand,  288 
Headache,  ice  compresses  in,  124 
Healing  of  wounds,  649 
by  first  intention,  649 
by  granulation,  649,  650 
by  secondary  intention,  649 
primary,  649 

Heart  disease,  dropsy  in,  712 
quick,  207 
slow,  207 
Heat,  741,  746 

as  rubefacient,  140 

dry,  application  of,  128 

sterilization  by,  448 

exhaustion,  698 

in  hemorrhage,  607 

in  inflammation,   121 

moist,  application  of,  131 

sterilization  by,  449 
of  inflammation,  120 
sterilization  by,  447 
unit,  748 

Heating  of  milk,  766 
Heat-stroke,  698 
in  animals,  699 
treatment  of,  699 
Hectic  fever,  199,  725 

in  phthisis,  199 
Heel,  bandage  of,  292 
Heller's  test  for  albuminuria,  279 


862 


INDEX 


Hematemesis,  257,  616 
Hematuria,  276,  280,  622 
Hemic  murmurs,  225 
Hemiplegia,  709 

Hemocytometer,  Thoma-Zeiss,  249 
Hemoglobin,  254 

estimation  of  percentage,  254 

Tallquist's  method  for  estimating,  254 
Hemoglobinometer,  von  Fleischl's,  253 
Hemophilia,  623,  624 
Hemoptysis,  616 

morphin  in,  617 

treatment,  617 
Hemorrhage,  594 

acetic  acid  in,  608 

actual  cautery  in,  607 

acupressure  in,  606 

adrenalin  chlorid  in,  608,  609 

after  abdominal  section,  581 
external,  582 
hypodermoclysis  in,  583 
internal,  582 
morphin  in,  582 
salt  solution  in,  583 

after-effects  of,  611 

alcohol  in,  611 

alum  in,  608 

anemia  after,  treatment,  612 

antepartum,  620 

arterial,  594 

astringents  in,  608 

atropin  in,  611 

auto-infusion  in,  611 

calcium  chlorid  in,  609 

capillary,  595 

cerebral,  623 

cold  in,  608 
water  in,  608 

concealed,  595,  613,  614 

connected  with  childbirth,  620 

digital  pressure  in,  603 

digitalis  in,  611 

ergot  in,  609 

ergotin  in,  609 

exposure  to  air  in,  598 

external,  595,  612 
acupuncture  in,  612 
treatment  of,  612 

from   bowels,    266,    614.         See    also 
Enterorrhagia. 

from  ear,  620 

from  kidneys,  622 

from  lungs,  610.    See  also  Hemoptysis. 

from  nose,  617.     See  also  Epistaxis. 

from  ruptured  Fallopian  tube,  622 

from  stomach,  616 

from  throat,  620 

from  urinary  tract,  622 

gallic  acid  in,  609 

gelatin  in,  609 

heat  in,  607 

hemostatics  in,  608 

hot  water  in,  607 

hypodermoclysis  in,  611 

in  labor,  620 

in  pregnancy,  620 

in  purpura,  623 

in  scurvy,  623 

in  typhoid  fever,   104 

internal,  595,  613 
cause  of,  614 

iron  in,  608 

ligature  in,  609 


Hemorrhage,  means  of  controlling,  596 

Monsell's  solution  in,  608 

morphin  in,  611 

postpartum,    621.          See    also    Post- 
partum  hemorrhage. 

pressure  in,  598 
digital,  603 
direct,  600 
indirect,  600,  603 

primary,  595 

revealed,  595,  613 

salt  solution  in,  611 

secondary,  595 

silver  nitrate  in,  608 

spontaneous,  595,  612,  623 

strychnin  in,  611 

styptic  collodion  in,  608 
cotton  in,  608 

styptics  in,  608 

subcutaneous,  595,  012 
cold  in,  613 
treatment  of,  613 

symptoms  of,  595 

tannic  acid  in,  608 

thirst  after,  treatment,  611 

torsion  in,  609,  610 

tourniquet  in,  604 

traumatic,  595,  612 

treatment  of,  596 

physical  condition,  610 

varieties  of,  595,  612 

venous,  594 

vinegar  in,  608 
Hemorrhagic  purpura,  623 
Hemorrhoids,  enterorrhagia  from,  treat- 
ment, 616 
Hemostatic,  definition  of,  342 

in  hemorrhage,  608 
Herpes,  731 

zoster,  732 
Hiccough,  715 

persistent,  222 
High  enema,  159 
High-tension  pulse,  203 
Hip,  handkerchief  bandage  for,  302,  303 

splint,  Thomas',  315 
Hippuric  acid  in  urine,  271 
Hirudo,  145 
History-taking,  254 
Hives,  732 
Hodgen's  splint,  316 
Hoffman's  anodyne,  349 
Homatropin,  effect  of,  on  eye,  241 
Home,  patient's,  operations  in,  555.    See 

also  Operations  in  patient's  home. 
Hookworm,  395 
Hopper,  cleaning  of,  835 

sterilizing,  468 
Horsehair  probang,  688,  689 

sutures,  489 

sterilization  of,  489 
Horizontal  position,  229 
Hospitals  for  children,   training-schools 
attached  to,  12,  14 

for  women,  training-schools  attached 
to,  12,  13 

general,  training-schools  attached  to, 
15 

private,  training-schools  attached  to, 
17 

special,   training-schools  attached  to, 
13 

training-schools  attached  to,  12 


INDEX 


863 


Host,  394 

Hot  applications,  128 
hath,  92 

for  cleansing  purposes,  94 
to  induce  perspiration,  95 
to  relieve  convulsions,  97 
bricks,  130 
compresses,  140 
dry  pack,  109 
foot-bath,  98 
pack,  108 

dry,  109 
sitz-bath,  97 

water  in  hemorrhage,  607 
Hot-air  bath,  110 
Hot-water  bag,   129 

after  operations,  571 
bottles,   130 
Housemaid's  knee,  829 
Hunger,  air,-  212 
Hyaline  casts  in  urine,  275 
Hydatid  cysts,  395 
Hydragogue,  definition  of,  342 
Hydrargyrum  chloridum  corrosivum  as 

antiseptic,  454 
Hydrocarbons,  740,  742 
Hydrochloric  acid,  752 
Hydrocyanic  acid,  poisoning  by,  373 
Hydrogen  pcroxid  as  antiseptic,  458 
Hyoscyamus,  poisoning  by,   treatment, 

384 

Hyperacidity,  gastric,  259 
Hyperchlorhydria,  259 
Hyperesthcsia,  703 
Hyperpyrexia,  194 
Hypertrophy,  248 
Hyphomycotes,  388 
Hypnotic,  definition  of,  342 
Hypodermic  injection,  354 
drugs  for,  355 

of  cocain  as  local  anesthetic,  354 
of  digitalin,  356 
of  digitaline,  356 
of  eucain  as  local  anesthetic,  354 
of  Schleich's  solution,  354 
technic,  356 
needle,  infection  from,  419 

sterilization  of,  480 
syringe,  357 
tray,  356 

Hypodermoclysis,  514 
in  enterorrhagia,  615 
in  hemorrhage,  611 

after  abdominal  section,  583 
in  shock,  593 

after  abdominal  section,  581 
in  vomiting  after  operations,  575 
needles  for,  517 
sites  for,  517 
technics,  517 

HypophosphiteSi  Fellow's,  349 
Hysteria,  convulsions  in,  684 


ICE  compress,  123 

paddling,  116 

poultice,  128 

stupe,  125 

suppository,  171 
Ic-e-bag,  125 

Ice-chest,  cleaning  of,  835 
Ice-coils,  126 
Ice-cradles,  116 


I  Ice-cream,  767 
Ice-rub,   116 

Idiopathic  erysipelas,  660 
Idiosyncrasy,  influence  of,  on  dosage,  343 
Illumination  of  cavities,  239 
Illusion,  704 

Immersion,  constant,  in  water,  98,  99 
Immunity,  421 
active,  422 
acquired,  422 
Ehrlich's  theory,  428 
exhaustion  theory,  427 
Metchnikoff's  theory,  427 
natural,  412 
opsonic  theory,  429 
passive,  422 
Pasteur's  theory,  427 
theories  of,  426 
theory  of  the  feeding  cell,  427 
unity  of,  antitoxin,  426 
Wright's  theory,  429 
Impacted  fracture,  628 
Imperial  drink,  845 

pint,  332 

Impetigo  contagiosa,  735 
Improvised  tourniquet,  606 
Incised  wound,  648 
drainage  of,  653 
separation  of  tendons  in,  653 
treatment,  652 
Inclined  plane,  317 

double,  318 

Incontinence  of  urine,  222 
Incubation  period  in  infectious  diseases, 

431 

of  disease,  431 
of  fever,  725 
Index,  opsonic,  430 
Indican  in  urine,  283 
Indolent  granulation,  650 
Induration,  247 
|  Infant-feeding,  768 

carbohydrate  indigestion  in,  775 
dextrinized  barley-gruel,  844 
flour  with  buttermilk,  844 
fat  indigestion  in,  775 
indigestion  in,  775 
protein  indigestion  in,  775 
quantity,  774 
strength  of  food  in,  774 
Infection,  407 

by  inoculation,  415 
prophylaxis,  418 
droplet,  413 
in  wounds,  656 

from  bacillus  pyocyaneus,  656 
from      staphyloccoeeus      pyogenes 

aureus,  056 
local,  407 

of  wounds  with  pus-producing  organ- 
isms, 419 
systemic,  407 
wound,  440 

mixed,  442 
Infectious  diseases,  407 

drugs  with  specific  action  in,  432 
fever  in,  decline  of,  432 

fastigium  of,  432 
incubation  period,  431 
nursing  in,  433 
prophylaxis,  417 

•  treatment  by  injection  of  devital- 
ized bacteria,  430 


864 


INDEX 


Infectious  fevers,  722 

sputum,  262 
Inflammation,  119 

cold  in,  121 

counterirritation  in,   122 

heat  of,  120,  121 

in  wounds,  655 

interference  with  function  from,   120 

of  kidneys,  diet  in,  799 

pain  of,  120 

redness  of,  120 

swelling  of,  120 

treatment  of,  121 
Infusion,  continuous  rectal,  170 

dosage  of,  346 

intravenous,  of  salt  solution,  519 
technic,  520 

subcutaneous,  of  salt  solution,  514 
Inhalation,  administering  drugs  by,  358 
for  stimulation,  364 

of  ammonia  fumes,  364 

of  amyl  nitrite  vapor,  365 

of  saltpeter  for  asthma,  365 

of  steam,  365 
Inhalations  for  throat,  367 
Inhaler,  chloroform,  359 

Clover,  360 
Ink-stains  on  linen,  removal,  820 

on  scrubbed  wood,  removal,  833 
Inoculation,  424 

infection  by,  415 
prophylaxis,  418 

Pasteur's  method,  424 

with  attenuated  virus,  424 
Inorganic  murmurs,  225 
Insects  as  transmitters  of  specific  dis- 
eases, 420 

stings  of,  672 
Insolation,  698 
Insomnia,  706 

acute,  706 

chronic,  707 

in  children,  708 
Inspection,  223 
Instep,  figure-of-8  bandage  of,  291 

spica  of,  291 
Instruments,  closet  for,  482 

for  intubation,  O'Dwyer's,  589 

in  operating-room,  548 

sharp,  sterilization  of,  479 

sterilization  of,  478 

in  operations  in  private  house,  561 

surgica|,  inventory  of,  817 
Intermediate  pulse,  207 
Intermittent  fever,  197,  724 

malaria,  temperature  chart  in,  198 
Intestinal  disorders,  acute,  diet  in,  793, 

794 

chronic,  diet  in,  793,  796 
diet  in,  792 

irrigation,  16.7-     See  also  Enteroclysis. 

juice,  752,  753 

obstruction  after  abdominal   section, 

579 

Intestine,  distention  of,  after  abdominal 
section,  579 

perforation  of,  624 

peristalsis  in,  754 
Intra-uterine  douche,  174 
Intravenous  infusion  of  salt  solution,  519 

technic,  520 
Introduction,  11 
Intubation,  589 


Intubation  instruments,  O'Dwyer's,  589 
Inunction,  administering  drugs  by,  3G8 
Invasion  period  of  disease,  432 
Inventories,  ward,  816 
Invert  sugar,  742 
Invertin,  753 

lodin  solution,  Harrington's,  463 
stains  on  linen,  removal,  821 

on  scrubbed  wood,  removal,  833 
tincture  of,  as  counterirritant,  146 
Iodized  catgut,  492 
lodoform  as  antiseptic,  459 
color  of  urine  in,  273 
gauze,  498 

sterilization  of,  498 
powder,  sterilization  of,  496 
Ipecacuanha,    wine    of,    as    emetic    in 

poisoning,  371 

Iris  diaphragm  of  microscope,  397 
Iron  in  epistaxis,  619 
in  hemorrhage,  608 

Ironing  surface  as  remedy  for  pain,  147 
Iron-rust  stains  on  linen,  removal,  821 
Ironware,  enamel,  cleaning  of,  831 
Irregular  fever,  725 
pulse,  207 
respiration,  212 
Irrigation,  bladder,  186 
in  operations,  553 

in  private  houses,  562 
intestinal,  167.     See  also  Enteroclysis. 
preparation  for,  510 
Irritant  poisons,  372,  375 
physiologic  dose,  375 
poisonous  doses,  375 
table  of,  377-380 
Irritants,  poisoning  by,  375 
acute,  375 
convalescence  from,  376 

sequels  of,  376 
«     chronic,  375,  381 
Irritating  drugs,  time  of  administering, 

346 
Itch,  rash  in,  733 


JACKET,  cotton,  130 
pneumonia,  130 

§oultice,  134 
ayre's,  306 

Jaundice,  244,  245 

color  of  skin  in,  244,  245 

Jaw,  bandage  of,  294 

figure-of-8  bandage  of,  294 
four-tailed  bandage  of,  298 
lower,  dislocation  of,  treatment,  647 
fracture  of,  treatment,  641 

Jelly,  barley,  844 
milk,  767,  841 
oatmeal,  844 

Jerky  respiration,  212 

Junket,  767,  841 

Jury-mast,  Sayre's,  307 


KANGAROO  tendon  suture,  495 

sterilization  of,  495 
Kefir,  766 

Kelly  pad,  improvised,  84 
Kelly's  method  of  sterilization  of  hands, 

472 

Keloid,  659 
Kerosene  oil  as  vesicant,  152 


INDEX 


865 


Kettle,  croup,  111,  466 
Kidneys,  hemorrhage  from,  622 

inflammation  of,  diet  in,  799 

operations  on,  sterilization  in,  474 
Kilogram,  abbreviation  for,  337 
Kitchen  crockery,  cleaning  of,  834 
Kite-tail  tampon,   181 
Klebs-LOffler  bacillus,  392 
Knee,  forced  flexion  of,  C01 

fracture  of,  treatment,  637 

housemaid's,  829 

splint,  Thomas',  315 
Knee-chest  position,  231 
Knot,  327 

clove-hitch,  329 

granny,  327,  328 

reef,  328 

square,  328 

surgeon's,  328 
Koch's  postulates,  410,  411 

tuberculin,  425 
Koplik's  spots,  729 
Koumiss,  766,  841 


LABARRAQUE'S  solution,  283,  350,  462 
Label  on  bottle,  reading,  352 
Labor,  hemorrhage  in,  620 
Lacerated  wound,  649 

treatment,  654 
Lactalbumin,  768 
Lacteals,  755 
Lactose,  742 

Lady  Webster's  pills,  350 
Laminectomy,  644 
Lamp,  Schering's,  464,  465 
Laparotomy,  575.      See  also  Abdominal 

section. 

Laryngoscopy,  242,  243 
Laryngotomy,  position  for,  587 
Larynx,  foreign  bodies  in,  089 
Laudanum,  349 
Laundry  books,  ward,  818 
Lavage  of  stomach,  188 
first  step,  189 
in  poisoning,  370 
in  vomiting  after  operations,  574 
second  step,  190 
third  step,   191 

Laxatives,  time  of  administering,  346 
Lead  and  laudanum  lotion,   125 

plaster,  153 

Lecturers  in  training-schools,  45 
Leech,  145 
Leeching,   145 
Left  lateral  position,  231 
Leg  bath,  99,  100 

fracture  of,  treatment,  immediate,  632 

rest-,  288 

supporting  of,  by  hand,  288 

ulcer  of,  adhesive  strapping  in,  326 
Leiter's  coils,   126 
Lemonade,  845 
Lens,  crystalline,  240 
Lenticular  papules,  246 
Lentigo,  246 

Leprosy,  infection  by,  416 
Leukemia,  252 
Leukocytes,  250 

ameboid  movements,  251 

nucleus  of,  251 
Leukocytosis,  251 
Leukopenia,  251,  252 

55 


Levis  splint,  314 
Levulose,  742 
Lifting  patient,  87 
from  bed,  88 
in  bed,  87 
Ligatures,  487 

in  hemorrhage,  609 

sterilization  of,  487 
Lightning,  burns  by,  670 
Limbs,   operations   on,    sterilization   in, 

475 
Lime,  chlorinated,  as  antiseptic,  462 

milk  of,  as  antiseptic,  461 
Lime-water  in  milk,  765 
Linen,    bichlorid   of   mercury   stain   on, 
removal,  821 

blood-stains  on,  removal,  820 

care  of,  ward,  820 

coffee  stains  on,  removal,  821 

disinfection  of,  821 

fecal  stains  on,  removal,  820 

fruit-stains  on,  removal,  821 

grease  stains  on,  removal,  821 

ink-stains  on,  removal,  820 

inventory,  817 

jodin  stains  on,  removal,  821 

iron-rust  stains  on,  removal,  821 

oil  stains  on,  removal,  821 

supply  of  operating-room,  547 

tea  stains  on,  removal,  821 

torn,  repair  of,  821 
Liniments,  152 

soap,  153 

Linseed  poultice,  131 
Linseed-tea,  846 
Liquid  diet,  782 
Lister,  Joseph,  409 
Liter,  336 

abbreviation  for,  337 
Lithia  in  urine,  271 
Lithotomy  position,  229 

in  operation  in  private  house,  560 
Lobar  pneumonia,     temperature     chart 

of,  197 

Local  applications,  119 
Loffler's  blood-serum  as  culture-media, 

405 
Logwood,  color  of  urine  from,  273 

coloring  stools,  267 
Long  splint,  311 
Loring's  ophthalmoscope,  240 
Louse,  bite  of,  rash  in,  734 
Low  enema,  159 
Low-tension  pulse,  203 
Lumbar  puncture,  524 

lateral  position  for,  525 
sitting  posture  for,  525 
Lunar  caustic,  350 

as  antiseptic,  460 
Lungs,  bacteria  in,  413 

hemorrhage    from,    616.          See    also 

Hemoptysis. 

Luxation,  645.      See  also  Dislocation. 
Lymphocytes,  large,  251 

small,  251 
Lysis,   196,  422 

of  fever,  724 
Lysol  as  antiseptic,  457 


MACHINE,  hand  roller-bandage,  287 
Mackintoshes,  sterilization  of,  487 
Macular  rash,  246 


860 


INDEX 


Macule,  246 

Magendie's  solution,  349 
Magnesia  in  urine,  271 
Making  a  bed,  63 

Malaria,  intermittent,  temperature  chart 
in,  198 

prophylaxis,  420 

quinin  in,  433 

transmission  of,  by  mosquitos,  394 
Malignant  anemia,  color  of  skin  in,  245 
Maltose,  742,  752,  753 
Many-tailed  bandage,  298 

of  abdomen,  299 
Marble,  cleaning  of,  831 
Massage  in  constipation,  717 

in  fractures,  635 
Mattresses,  60 

cotton,  60 

feather,  60 

fresh,  giving  of,  69 

hair,  61 

palm  fiber,  60 

straw,  60 

turning  of,  69 
Matzoon,  766 

Measles,  German,  nursing  in,  437 
rash  irr,  729 

nursing  in,  436 

rash  in,  728 
Measly  pork,  396 
Measures,  330 

metric,  334 
Measuring  solutions,  469 

by  apothecaries'  measure,  469 
by  metric  system,  469 
Measuring-glasses,  333 
Meat,  albumins  of,  effect  of  cooking  on, 
760 

broths,  777 

diet  of,  784 

extracts,  777 
Meat-teas,  844 
Meatus,  urinary,  184 
Meconium,  264 
Medical  bed,  changing  of,  65 
Medicated  enema,  164 

gauze,  497 

purgative  enema,  164 

stupes,  139 

tub-baths,  105 
Medicine  chest,  ward,  352 
Medicines,  330 
Melangeur,  249 
Melanotic  stools,  267 
Meningitis,  spinal,  convulsions  in,  683 
Mental  condition  as  symptom,  221    • 
Mercury  and  ammonia  plaster,  153 

bichlorid  of,  as  antiseptic,  454 
as  vaginal  douche,  174 
stain  from,  removal  from  linen,  821 

by  inunction,  368 

in  syphilis,  433 
Meringues,  843 
Merismopedia,  390 
Metabolism,  747 

Metal  catheters,  sterilization  of,  486 
Metals,  cleaning  of,  834 
Metchnikoff's  theory  of  immunity,  427 
Meter,  335 

abbreviation  for,  337 
Methylene-blue,  color  of  urine  from,  273 

coloring  stools,  267 
Metric  system,  334 


Metric    system,  approximate  values  of 

measures,  337 
changing  apothecaries'  measure  to, 

338 

common  measures,  337 
measure  of  capacity,  335 
of  length,  334 
of  volume,  336 
measuring  solutions  by,  469 

weights,  337 
Microbes,  388 
Micrococci,  390,  392 
Micromillimeter,  395 
Micron,  395 

Micro-organisms,  387.       See  also  Bac- 
teria. 
Microscope,  396 

Abbs'  condenser,  397 

compound,  396 

high  power,  396 

iris  diaphragm,  397 

low  power,  396 

oil-immersion  lens,  397 

parts  of,  396 

simple,  396 

Microscopic  examination  of  urine,  276 
Milk,  762 

as  culture-media,  405 

as  food  for  infants,  768 

chemical  composition,  763 

composition  of,  768 

diet,  feces  of,  264 

dilution  of,  765 

fat-free,  764 

fermentation  of,  766 

flavoring  of,  767 

heating  of,  766 

human,  composition  of,  768 

indigestibility  of,  763 

keeping  pure,  772 

lessening  acidity,  765 

lime-water  in,  765 

modification  of,  769 

Baner's  formula  for,  770 

of  lime  as  antiseptic,  461 

pasteurization  of,  772,  840 
^peptpnizing,  841 

predigestion  of,  766 

protein  of,  768 

recipes  for,  840 

rice-,  846 

skimmed,  764 

splitting  up,  764 

sterilization  of,  772,  840 
Milk-curds,  765,  841 
Milk-jelly,  767,  841 
Milk-punch,  768,  842 
Milky  urine,  273,  282 
Mjllimeter,  abbreviation  for,  337 
Mindererus,  spirits  of,  349 
Mineral  salts,  743 

waters,  779 
Minim,  332 

abbreviation  for,  331 
Mitigated  silver  stick,  460 
Mixed  infection  of  wounds,  442 
Mixing  solutions  from  crude  drug,  470 
Mixture,  Basham's,  349 

Brown,  349 

dosage  of,  347 
Modification  of  milk,  769 

Baner's  formula  for,  770 
Moist  cold,  application  of,  123 


INDEX 


867 


Moist  gangrene,  658 

heat,  application  of,  131 
sterilization  by,  449 

papule  in  syphilis,  730 

rales,  224 
Molds,  388 
Monococci,  392 
Monsell's  solution,  350 
in  hemorrhage,  608 
Mopping  floors,  ward,  828 
Mops  in  operating-room,  546 
Morbid  changes,  248 
Morphin  in  enterorrhagia,  615 

in  hemoptysis,  617 

in  hemorrhage,  611 

after  abdominal  section,  582 
Mosquitos,  extermination  of,  as  preven- 
tive of  malaria  and  yellow  fever,  420 

transmission  of  malaria  by,  394 

of  yellow  fever  by,  394 
Motility  of  bacteria,  393 
Motor  activity  of  stomach,  determina- 
tion, 259 
Mouth,  administering  drugs  by,  351 

bacteria  in,  413 

care  of,  74 

condition  of,  as  symptom,  221 

operations  on,  sterilization  in,  476 

taking  temperature  in,  201 
Mouth-wash,  76 
Mucoid  sputum,  260 
Mucopurulent  sputum,  260 
Mucous  patches  in  syphilis,  730 
Mucus  in  stools,  265 

in  urine,  282 

in  vomitus,  257 
Mulford  antitoxin  phial,  522 
Mulberry  rash,  729 
Mumps,  nursing  in,  437 
Muriatic  acid,  349 
Murmurs,  224,  225 

hemic,  225 

inorganic,  225 
Muscles,  sternocleidomastoid,  action  of, 

in  respiration,  214 
Muscular  power,  741,  746 
Mushroom-poisoning,  treatment,  384 
Mustard  bath,  105 

French,  141 

paste,  140 

plaster,  140 
in  shock,  593 

poultice,  134 
Mustard-leaf,  141 
Muttering  delirium,  low,  703 
Mutton-broth,  777,  845 
Mydriatic,  definition  of,  240,  342 
Myxedema,  induration  of  skin  in,  247 


XAIL-CLEANERS,  sterilization  of,  500 
Xape   of  neck,  figure-of-8   bandage   of, 

295 
Narcotic,  definition  of,  342 

time  of  administering,  345 
Xares,  242 

plugging,  in  epistaxia,  619 

posterior,  242 
Nasal  douche,  176 

feeding,   192 
Natural  immunity,  421 

resistance  of  body,  421 
Nausea  after  operations,  573 


Neck,  glands  of,  operations  ou,  steriliza- 
tion in,  475 

nape  of,  figure-of-8  bandage  of,  295 
Needles,  479 

aneurysm,  480 

hollow,  sterilization  of,  480 

hypodermic,  sterilization  of,  480 

sterilization  of,  479 
Negative  chemotaxis,  390 
Nematodes,  395 
Nephritis,  diet  in,  799 

dropsy  in,  711 

in  burns,  669,  670 

parenchymatous,  waxy  casts  in,  275 
Nervous  diseases,  cold  bath  in,  104 
Nettle-rash,  732 

Neutrophiles,  polymorphonuclear,  251 
Newborn,  asphyxia  of,  694 

artificial  respiration  in,  694 
Byrd's  method,  695 
Schultze's  method,  694 

white  asphyxia  of,  696 
Nickel,  cleaning  of,  834 
Night  nurse,  808 

report,  ward,  814 
Nipples,  rubber,  care  of,  773 
Nitric  acid,  poisoning  by,  373 
test  for  albuminuria,  279 
Nitrites,  action  of,  344 
Nitrogenous  foods,  741 
Nitrous  oxid  anesthesia,  359 
Nits  in  hair,  examination  for,  86 

treatment,  86 
Nodules,  246 

Non-pathogenic  bacteria,  389 
Nose,  bacteria  in,  413 

condition  of,  as  symptom,  221 

examination  of,  242 

foreign  bodies  in,  removal  of,  687 

hemorrhage    from,    617.          See    also 
Epistaxis. 

operations  on,  sterilization  in,  476 
Nucleus  of  leukocytes,  251 
Nummular  sputum,  262 
Nurse,  central  preparatory  school  for,  48 

character  of,  32 

clean,  502.      See  also  \urse,  sterile. 

domestic  training  of,  53 

duties  of,  in  emergency  operations,  553 
in  operating-room,  547 

education  of,  33 

hands  of,  cleansing,  507,  508 

head,  805 

special  duties.  824 
visiting  rounds,  838 

methods  of  teaching,  23 

night,  808 

physical  qualifications  of,  31 

qualifications  of,  30 

registration  of,  20 

salary  of,  38 

social  state,  36 

sterile,  502 

in  operating-room,  549 
(No.  1),  duties  of,  503 

teaching  of,  methods,  23 

training  of,  essentials,  19 

unsterile,  502 

in  operating-room,  551 
(No.  2),  duties  of,  505_ 
Nursing  bottles,  care  of,  773 

commercial  valuation,  38 

in  chicken-pox,  437 


868 


INDEX 


Nutrient  bouillon  as  culture-media,  405 
Nutritive  enema,  162 


OATMEAL,  776 

gruel,  843 

jelly,  844 

poultice,  135 

water,  846 

Objective  symptoms,  219,  220 
Obligate  bacteria,  389 
Observation,  219 
Odor  of  breath  as  symptom,  221 

of  stools,  266 

of  urine,  273 

O'Dwyer's  intubation  instruments,  589 
Oese,  398 
Oil,  carron,  350 

croton,  as  vesicant,  152 

enema,  164 

kerosene,  as  vesicant,  152 

poultice,  136 

stains  on  linen,  removal,  821 

sterilization  of,  496 
Ojl-immersion  lens  of  microscope,  397 
Oily  casts  in  urine,  276 
Ointment,  cantharidal,  as  vesicant,  150 

savin,  151 

sterilization  of,  496 
Olein,  742 
Oliguria,  274 
Operating-room,  537 

anesthetist's  table,  541 

basins  in,  544 

cupboards  in,  543 

duties  of  nurses  in,  547 

emergency  table,  542 

equipment  of,  537 

furniture  of,  537 

gowns  in,  546 

instruments  in,  548 

linen  supply  of,  547 

mops  in,  546 

operating-table,  538 

patient's  dress  in,  546 

pitchers  in,  544 

preparation  table,  543 

reserve  table,  542 

sponge-receptacle  in,  544 

stands  in,  543 

sterile  nurse  in,  549 

unsterile  nurse  in,  551 

wash-stands  in,  544 

water-supply  of,  544 
Operating-table,  538 

Boldt's,  539 

crutches  on,  540 

in  private  house,  560 

pads  on,  540 

pillows  on,  540 

position  of  patient  on,  551 
of  patient's  arms  on,  551 
Operations,  bladder  conditions  after,  573 

care  after,  immediate,  570 
before,  565 

catharsis  before,  565 

eatheterization  after,  573 

cleansing  patient  before,  567 

condition  of  bladder  after,  573 

counting  sponges  in,  553 

diet  before,  566 

duties  of  nurse   after  closure  of  in- 
cision, 554 


Operations,  duties   of    nurse   between, 

555 
emergency,  catharsis  before,  566 

duties  of  nurse  in,  553 
ether  bed,  569 
etherization  for,  568- 
field  of,  preparation,  473 
hot-water  bags  after,  571 
immediate  care  after,  570 

preparation  for,  567 
in  patient's  home,  555 

after  the  operation,  564 
carrying  patient,  563 
gowns,  562 
irrigation  in,  562 
outfit  of  nurse,  557 
position  of  patient,  560 
sterilization  of  instruments,  561 
protecting  floor,  560 
requirements,  556 
room  for,  558 

arrangement,  561 
salt  solution  in,  557 
sterilizer  in,  558 
table  for,  560 
irrigations  in,  553 
nausea  after,  573 
on  eye,  584 
care  after,  585 
pain  after,  585 
Paquelin  cautery  in,  553 
preparatory  period,  565 

immediate,  567 
pulse  after,  572 
respiration  after,  572 
restlessness  after,  572 
sheet,  549 
thirst  after,  575 

urinary  examination  before,  565 
vomiting  after,  573 

bismuth  subnitrate  in,  575 
bromids  in,  575 
cerium  oxalate  in,  575 
cocain  hydrochlorid  in,  575 
hypodermoclysis  in,  575 
lavage  of  stomach  for,  574 
salt  solution  in,  575 
Ophthalmia,  infection  by,  416,  419 
of  newborn,  douching  eye  in,  180 

ice  compresses  in,  124 
Ophthalmoscope,  241 

Loring's,  240 
Opisthotonos,  677 
Opium  plaster,  153 

poisoning,    phvsiologic   antidote   for, 

370 

treatment,  384 
Opsonic  index,  430 
potency,  430 
theory  of  immunity,  429 
Opsonins,  429 
Orange-red  urine,  272 
Orbit,  fracture  of,  treatment,  641 
Orderly,  809 
Organic  acids,  744 

matter  in  urine,  271 
Orthopnea,  212 
Ounce,  abbreviation  for,  331 
Oxalic  acid,  poisoning  by,  treatment,  373 
Oxaluria,  diet  in,  801 
Oxidation,  739,  746 
Oxygen,  value  of,  739 
Oxytocic,  definition  of,  342 


INDEX 


869 


PACKING  cavity,  512 

sinus,  512 

vagina,  181 
Pack,  92 

cold,  117 

hot,  108 
dry,  109 

wet,  117 

Pad,  Kelly,  improvised,  84 
Padding  splints,  308 
Paddling,  ice,  116 
Pads  on  operating-table,  540 
Pain,  701 

after  operations  on  eye,  585 

boring,  701 

character  of,  as  symptom,  220 

causes  of,  701 

dull,  701 

influence  of,  on  dosage,  344 

lancinating,  701 

of  inflammation,  120 

onset  of,  702 

sharp,  701 

symptoms  of,  objective,  702 
subjective,  701 

throbbing,  701 

varieties  of,  701 
Palate,   operations   on,    sterilization   in, 

476 

Pallor,  244 

Palm  fiber  mattress,  60 
Palmitin,  742 
Palpation,  223 
Pancreatic  juice,  752 
Pap,  844 
Papular  eczema,  733 

rash,  731 
Papule,  246 

lenticular,  246 

moist,  in  syphilis,  730 

pustular,  246 

vesicular,  246 
Paquelin  cautery,  147,  148 
in  operations,  553 
sterilization  of,  481 
Paracentesis,  528 
Paralysis,  222,  709 

facial,  711 

Paraplegia,  709,  710 
Parasites,  389,  304 

in  feces,  268 
Paregoric,  349 
Parenchymatous  nephritis,  waxy  casts 

in,  275 

Paronychia,  675 
Paste,  mustard,  140 
Pasteur,  Louis,  409 
Pasteurization  of  milk,  772,  840 
Pasteur's  method  of  inoculation,  424 

theory  of  immunity,  427 
Patella,  fracture  of,  treatment,  637 
Pathogenic  bacteria,  389 

action  of,  431 
Pediculi  in  hair,  examination  for,  86 

treatment,  86 
Pediculosis,  734 
Pelvic  spica,  291 

Pelvis,  fracture  of,  treatment,  641 
immediate,  634 

rest  for,  288 

support  of,  by  hand,  288 
Peptonizing  milk,  841 
Percussion,  225 


Perfection  bed-pan,  83 
Perforation,  624 

in  typhoid  fever,  104 

symptoms  of,  624 

treatment  of,  624 
Pericardium,  aspiration  of,  535 

exploratory  puncture  of,  524 
Perineum,    handkerchief    bandage    for, 

302 
Peristalsis,  159 

in  stomach  and  intestine,  754 
Peritoneal  cavity,  aspiration  of,  531-533 

fluid  in,  paracentesis  in,  529 
Permanganate  of  potash  as  antiseptic, 

458 
Pernicious    anemia,    color    of    skin    in, 

245 

Petechia,  247,  613 
Petri  dish,  403 
Pewter,  cleaning  of,  834 
Phagocytes,  120,  427 

function  of,  421 
Phenol,  350 

as  antiseptic,  456 
Phlebotomy,  521 
Phosphates  in  urine,  278 

triple,  in  urine,  276 
Phosphoric  acid  in  urine,  271 
Photogenic  bacteria,  390 
Phthisis,  diet  in,  802 

hectic  fever  in,  199 
Physical  qualifications  of  nurse,  31 

signs,  220,  223 
Physiologic  antidote,  370 

limit  of  drug,  369 
Picking  at  bed-clothes,  222 
Picric  acid  in  burns,  667 
Pigmented  patches  on  skin,  245 
Pigments  in  urine,  271 
Pillows,  61 

down,  61 

feather,  61 

hair,  61 

on  operating-table,  540 
Pills,  A.  B.  and  S.,  350 

Blaud's,  350 

blue,  350 

Lady  Webster's,  350 

Plummer's,  350 

Pilocarpin   in   conjunction   with   sweat- 
bath,  109 
Pjnk  urine,  273 
Pint,  abbreviation  for,  331 

Imperial,  332 
Pin-worm,  396 

Pitchers  in  operating-room,  544 
Plague,  bubonic,  infection  by,  416 
Plane,  inclined,  317 

double,  318 
Plaster,  153 

adhesive,  154 

anodyne,  153,  154 

asafetida,  153 

belladonna,  153 

cantharides,  150 

capsicum,  153 

diachylon,  153 

lead,  153 

mercury  and  ammonia,  153 

mustard,  140 

opium,  153 

removal  of,  154 

soap,  153 


870 


INDEX 


Plaster-of-Paris  bandage,  304 
interrupted,  305,  306 
opening  in,  305 
technique  of  applying,  304 
Plating,  403 

Pleura,  aspiration  of,  534,  535 
Plugging  nares  in  epistaxis,  619 
Plummet's  pills,  350 
Pneumonia  jacket,  130 

lobar,  temperature  chart  of,  197 
poultice  in,  134 
Poached  egg,  842 
Poisoning,  369 

apomorphin  as  emetic  in,  371 

blood-,  441 

by  acetanilid,  treatment,  383 

by  aconite,  treatment,  382 

by  alcohol,  treatment,  382 

by  antifebrin,  treatment,  383 

by  antipyrin,  treatment,  383 

by  belladonna,  treatment,  383 

by  carbolic  acid,  treatment,  373 

by  chloral,  treatment,  383 

by  cocain    hydrochlorid,    treatment, 

384 
by  corrosives,  372 

convalescence  from,  373 
symptoms,  372 
treatment,  372 
by  daturin,  treatment,  385 
by  digitalis,  treatment,  384 
by  functional  poisons,  381 
by  hydrocyanic  acid,  375 
by  hypscyamus,  treatment,  384 
by  irritants,  375 
acute,  375 

convalescence  from,  376 
sequels  of,  376 
chronic,  375,  381 
by  nitric  acid,  373 
by  opium,  physiologic  antidote  for, 

370 

treatment,  384 

by  oxalic  acid,  treatment,  373 
by  snake-bite,  treatment,  386 
by  stramonium,  treatment,  385 
by  strychnin,  convulsions  in,  683 

treatment,  385 
by  sulphuric  acid,  373 
by  veratrum  viride,  treatment,  386 
carbonate  of  ammonia  as  emetic  in, 

371 

emetics  in,  370 
lavage  in,  370 

mushroom-,  treatment  of,  384 
treatment  of,  369 

wine  of  ipecacuanha  as  emetic  in,  371 
zinc  sulphate  as  emetic  in,  371 
Poisons,  369 

antidotes  for,  369 
corrosive,  371,  372 

table  of,  374 
functional,  372,  381 
in  feces,  268 
irritant,  372,  375 

physiologic  dose,  375 
poisonous  doses,  375 
table  of,  377-380 
Poliomyelitis,  acute  anterior,  711 
Poljshed  furniture,  care  of,  832 
Polishing  floors,  ward,  829 
Politzer'a  bag,  244 
Polyuria,  274 


!  Pomphi,  246 
Pons,  710 

Poppy-head  stupe,  139 
Porcelain,  care  of,  in  ward,  832 
Pork,  measly,  396 
I  Poroplastic  felt,  318 
Position  after  abdominal  section,  576 

dorsal,  229 

recumbent,  229 

for  laryngotomy,  587 

for  tracheotomy,  587 

genupectoral,  231 

horizontal,  229 

knee-chest,  231 

left  lateral,  231 

lithotomy,  229 

in  operation  in  private  house,  56C 

Sims',  231 

standing,  234 

Trendelenburg,  233 

in  operations  in  private  house,  560 
Positive  chemotaxis,  390 
Posterior  nares,  242 
Postpartum  hemorrhage,  621 
ergot  in,  621 
primary,  621 
salt  solution  in,  621 
secondary,  621 
treatment,  621 
Potash  in  urine,  271 
Potassium  iodid  in  syphilis,  433 

permanganate  as  antiseptic,  458,  459 
Potato  bacillus,  393- 

raw,  as  culture-media,  405 
Potential  energy  of  food,  748 
Pott's  fracture,  treatment,  636 
Poultice,  131 

bread,  135 

charcoal,  135 

flaxseed,  131 

digitalis,  136 

flaxseed,    addition    of    glycerin    and 

belladonna  to,  135 
addition  of  opium  to,  135 

foxglove,  136 

ice,  128 

jacket,  134 

linseed,  131 

mustard,  134 

oatmeal,  135 

of  ground  corn,  135 

oil,  136 

soap,  136 

spice,  142 

starch,  136 

wheatmeal,  135 
Pound,  abbreviation  for,  331 
Powder,  B.  B.  C.,  460 

Dover's,  349 

dusting-,  sterilization  of,  495 

gray,  349 

Gregory,  349 

iodoform,  sterilization  of,  496 

Seidlitz,  350 

Tully's,  350 
Practical  methods,  59 
Predigestion  of  milk,  766,  841 
Pregnancy,  hemorrhage  in,  620 

uremia  in,  682 

vomiting  in,  714 
Preparation  table  in  operating-room,  543 

tray  for  sterilization  of  skin,  508 
Preparations,  familiar,  349 


INDEX 


871 


Preparations,  relative  values  of,  346 
Preparatory  schools,  central,  for  nurses, 

48 

Pressure,  digital,  in  hemorrhage,  603 
of  brachial  artery,  598 
of  femoral  artery,  602 

direct,  in  hemorrhage,  600 

in  hemorrhage,  598 

indirect,  in  hemorrhage,  600,  603 

of  facial  artery,  603 

of  radial  artery  at  wrist,  600 

of  subclavian  artery,  601 

of  temporal  artery,  602 

of  ulnar  artery  at  wrist,  600 

relieving  of,  81 
Pressure-sore  from  splint,  309 
Private  house,  operations  in,  555.      See 

also  Operations  in  patient's  home. 
Probang,  688 

horsehair,  688,  689 
Prodromes,  431,  432,  723 
Profuse  sputum,  260 

vomiting,  256 
Projectile  vomiting,  257 
Proof  spirit,  459 

Protective  in  dressing  of  burns,  513 
Protein,  739,  740 

digestion  of,  751 

effect  of  cooking  on,  760 

of  milk,  768 
Protozoa,  388,  394 
Provisional  callus,  630 
Prune-juice  sputum,  261 
Prussic  acid,  350 
Ptomain,  407 

Ptyalagogue,  definition  of,  342 
Ptyalin,  752,  753 
Puerperal  fever,  440 
Pulmonary  embolism,  659 
Pulse,  202 

after  operations,  572 

capillary,  208 

compressible,  205 

Corrigan's,  208 

dicrotic,  208 

frequent,  207 

full,  205 

and  bounding,  205 

hard,  205 

high-tension,  203 

intermediate,  207 

irregular,  207 

low-tension,  203 

quick,  207 

rapid,  207 

regular,  207 

resistant,  205 

size  of,  205 

slow,  207 

small,  205 

soft,  205 

taking  of,  202 

at  common  carotid  arteries,  202 
at  facial  artery,  202 
at  femoral  artery,  202 
at  radial  artery,  202 
at  temporal  artery,  202 

tension  of,  203 

thready,  205 

varieties  of,  206 

volume  of,  205 

water-hammer,  208 

wiry,  206 


Pump,  air-,  sterilization  of,  482 

Punctiform  rashes,  245 

Puncture,  exploratory,   of  pericardium, 

524 

lumbar,  524.     See  also  Lumbar  punc- 
ture. 

Punctured  wound,  649 
tetanus  from,  654 
treatment,  654 
Purgative,  definition  of,  342 
enema,  compound,   165 

medicated,  164 
Purpura,  epistaxis  in,  618 

hemorrhagic,  623 
Purulent  sputum,  261 
Pus,  121,  441 
blue,  440,  656 
casts  in  urine,  276 
in  feces,  266 
in  sputum,  261 
in  urine,  276,  281 
in  vomitus,  258 
Pustulants,  140,  152 
Pustular  papules,  246 
Pustules,  246,  441 
Pustulous  eczema,  733 
Putrefactive-  alkaloids,  408 
Pyemia,  440 
Pyogenic  bacteria,  439 

incubation  period,  442 
Pyrcxia,  194 
Pyuria,  281 


QUALIFICATIONS  of  nurse,  30 
Quassia  enema,  166 
Quick  heart,  207 

pulse,  207 
Quinin,  full  doses,  symptoms  of,  386 

in  malaria,  433 


RABIES,  671 

infection  by,  416,  418 
Race,  influence  of,  on  dosage,  343 
Radial  artery,  compression  of,  at  wrist, 
600 

pulse,  202 

Raising  patient  into  sitting  posture,  88 
Rales,  224 

bronchial,  225 

bubbling,  225 

coarse,  225 

crackling,  225 

crepitant,  225 

dry,  225 

fine,  225 

gurgling,  225 

moist,  224 

sibilant,  225 

sonorous,  225 

tracheal,  225 

vesical,  225 
Rapid  pulse,  207 
Rash,  245 

accidental,  731 

acne,  731,  733 

circumscribed,  245 

diffuse,  245 

erythematous,  245,  731 

in  chicken-pox,  727 

in  eczema,  733 

in  erysipelas,  730 


872 


INDEX 


Rash  in  German  measles,  729 

in  itch,  733 

in  measles,  728 

in  pediculosis,  734 

in  roseola,  729 

in  rubella,  729 

in  rubepla,  728 

in  scabies,  733 

in  scarlet  fever,  727 

in  smallpox,  728 
confluent,  728 

in  syphilis,  730 

in  typhoid  fever,  729 

in  typhus  fever,  729 

in  varicella,  727 

macular,  246 

mulberry,  729 

nettle-,  732 

papular,  731 

punctiform,  245 

scarlatinous,  728,  731 

stomach,  732 

typhoid,  246 

Raw  potato  as  culture-media,  405 
Reaction,  diazo-,  Ehrlich's,  in  typhoid 
fever,  284 

of  urine,  272,  277 
Reaumur  thermometer,  200 
Receptors,  428 
Recipes,  840 

beverages,  845 

eggs,  842 

gruels,  843 

milk,  840 
Rectal  infusion,  continuous,  170 

suppository,  171 

tubes,  156 

sterilization  of,  485 
Rectum,  155 

administration  of  drugs  by,  353 

examination  of,  238 

operations  on,  sterilization  in,  475 

taking  temperature  in,   201 
Recurrent  bandage  of  head,  296 

of  stump,  293 
Red  corpuscles,  250 

stools,  267 

wash,  350 

Red-currant  jelly  sputum,  261 
Redness  of  inflammation,  120 
Reduction  of  dislocation,  645 
Redundant  granulation,  650 
Reef  knot,  328 
Reflex  vomiting,  713 
Registration  of  nurses,  20 

of  training-schools,  20 
Regular  pulse,  207 
Regurgitation,  713 
Relapse,  423 

Relapsing  fever,  infection  by,  416 
Remittent  fever,  197,  724 
Rennin,  764 
Repair  of  fractures,  629 

of  wounds,  652 
Report  book,  ward,  813 
Reporting  of  nurse,  812 
Reproduction  of  bacteria,  393 

vegetative,  393 

Reserve  table  in  operating-room,  .542 
Resistance,  natural,  of  body,  421 
Resistant  pulse,  205 
Resolution,  121,  247,  427 
Respiration,  209 


Respiration,  abdominal,  213 

restricted,  213 
action  of  sternocleidomastoid  muscles 

in,  214 

after  operations,  572 
artificial,  690 

Byrd's  method,  695 
Hall's  method,  69J 
in  drowning.  692 
Schultze's  method,  694 
Sylvester's  method,  690 
character  of,  211 
Cheyne-Stokes,  213 
crowing,  212 
deep,  211,  212 

estimation  of,  in  nervous  patients,  215 
grunting,  212 
irregular,  212 
jerky,  212 
mechanism  of,  213 
position  of  patient  in,  214 
rate  of,  211 
shallow,  211 
stertorous,  212 
stridulent,  212 
thoracic,  213 
tidal,  213 
Rest,  bed-,  89 
for  pelvis,  288 
in  bandaging,  287 
leg,  288 

Restlessness  after  operations,  572 
Restricted  abdominal  breathing,  213 
Retina,  240 

Returning  patient  to  bed,  89 
Revealed  hemorrhage,  595,  613 
Rheumatic  fever,  salicylic  acid  in,  433 

sweating  in,  treatment,  721 
Rhubarb,  color  of  urine  from,  273 
Rib,  fracture  of,  adhesive  strapping  in, 

324 

complications  from,  638 
treatment,  638 

immediate,  633 
Rice,  777 

Rice-flour  gruel,  843 
Rice-gruel,  843 
Rice-milk,  846 
Rice-water,  846 
Rickets,  744 

diet  in,  803 
Riegel's  test-meal,  258 
Rigor,  719 

treatment  of,  720 
Ringworm,  734 

treatment  of,  735 
Rochelle  salts,  350 
Roller  bandage,  286 

machine  to  roll,  287 
rules  for,  288 
Room,  disinfection  of,  464.        See  also 

Disinfection  of  room. 
for  operations  in  private  houses,  558 

arrangement,  561 

operating-,  537.      See  also  Operating- 
room. 

Roseola,  rash  in,  729 
Round-worms,  395 
Rub,  ice-,  116 

Rubber  bougies,  sterilization  of,  486 
catheters,  182 

sterilization  of,  485 
Esmarch  bandage,  287 


INDEX 


873 


Rubber  gloves,  sterilization  of,  484 

nipples,  care  of,  773 

sheeting,  62,  63 

sheets,  sterilization  of,  487 

sterilization  of,  483 

tissue,  sterilization  of,  485 
Rubefacients,  140 
Rubella,  rash  in,  729 
Rubeola,  rash  in,  728 
Rubner's  estimation  of  caloric  value  of 

food,  748 
Rupture  of  Fallopian  tube,  hemorrhage 

from,  622 
Rusty  sputum,  261,  262 


SACCHAROMYCETES,  388 

Salaries  paid  by  training-schools,  26-29 

Salary  of  nurse,  38 

Salicism,  386 

Salicylic  acid,  full  doses,  symptoms  of, 

386 

in  rheumatic  fever,  433 
Saliva,  752 
Salt  bag,  130 

solution  enema,  161,  163 
enteroclysis,  168 
in  enterorrhagia,  615 
in  hemorrhage,  611 

after  abdominal  section,  583 
in  lavage  of  stomach,  191 
in  operations  in  private  houses,  557 
in  postpartum  hemorrhage,  621 
in  shock,  593 

after  abdominal  section,  581 
in  vomiting  after  operations,  575 
intravenous  infusion,  519 

technic,  520 
normal,  460 

subcutaneous  infusion  of,  514 
Saltpeter,  inhalation  of,  for  asthma,  376 
Salts,  738 

definition  of,  341 
enema,  164 
Epsom,  350 
Glauber's,  350 
in  urine,  271 
mineral,  743 
Rochelle,  350 
Seidlitz,  350 
Salt-water  bath,  104 
Sand-bags,  323 

Santonin,  color  of  urine  from,  273 
Saprophytes,  389 
Sarcinse,  390,  392 
Saucepans,  cleaning  of,  834 
Sautter's  cradle,  323 
Savin  ointment,  151 
Sayre's  dressing  in  fracture  of  clavicle, 

325,  326 
jury-mast,  307 
spinal  jacket,  306 
Scabies,  rash  in,  733 
Scalds,  662 

treatment  of,  662.     See  also  Burns. 
Scales,  247,  727 
Scar  tissue,  649 

from  burns,  667 
Scarlatina     anginosa,     bleeding      from 

throat  in,  620 
Scarlatinous  rash,  728,  731 
Scarlet  fever,  condition  of  tongue  in,  221 
in  burns,  669 


Scarlet  fever,  infection  from  wounds,  661 
nursing  in,  435 
rash  in,  727 
Schatz's     method     of     sterilization     of 

hands,  472 

Schering's  lamp,  464,  465 
Schizpmycetes,  388,  391 
Schleich's    solution,    hypodermic    injec- 
tion of,  354 

School,  trainging-,  11.      See  also  Train- 
ing-school. 
Schools,  central  preparatory,  for  nurses, 

48 

Schott  system,   106 

Schultze's  method  of  artificial   respira- 
tion, 694 

Scrambled  egg,  842 

Scrubbed  wood,  stains  on,  removal,  833 
Scrubbing  floors,  ward,  828 
Scruple,  abbreviation  for,  331 
Scultetus  bandage,  298 
Scurvy,  744 

diet  in,  803 

epistaxis  in,  618 

hemorrhage  in,  623 
Sea-sponges,  499 

sterilization  of,  499 
Seat-worms  in  feces,  268 
Secretions,  bacteria  in,  414 
Section,    abdominal,    575.          See    also 

Abdominal  section. 
Sedative,  definition  of,  342 

stupe,  138 
Seepage,   170 
Seidlitz  powder,  350 
Senna,  color  of  urine  from,  273 
Sepsis,  440 

after  abdominal  section,  583 
Septicemia,  440 

from  wounds,  660 
Sequestrum,  657 
Serum,  antistreptococcus,  425 

antitoxin,  425.     See  also  Antitoxin. 

reaction  in  typhoid  fever,  401 
Sex,  influence  of,  on  sex,  343 
Shallow  respiration,  211 
Shaving,  unnecessary,  475 
Sheets,  63 

operation,  549 

rubber,  62,  63 

sterilization  of,  487 

top,  turning  of,  without  exposing  pa- 
tient, 68 
Shingles,  732 
Shirred  egg,  842 
Shirt  of  patient,  changing,  73 
Shivering,  719 

after  Brandt  bath,  103 

as  symptom  of  sepsis  after  abdominal 

section,  583 
Shock,  592 

after  abdominal  section,  581 

atropin  sulphate  in,  581 

digitalis  in,  581 

early,  581 

late,  581 

oil  of  camphor  in,  581 

salt  solution  in,  581 

strychnin  sulphate  in,  581 

after  an  accident,  593 

atropin  in,  593 

camphor  in,  593 

cerebral,  697 


874 


INDEX 


Shock,  dosage  in,  344 
electricity  in,  593 
ether  in,  593 
hypodermoclysis  in,  593 
in  accidental  wounds,  650 
in  burns,  668 
mustard  plaster  in,  593 
salt  solution  in,  593 
strychnin  in,  593 
symptoms  of,  592 
treatment  of,  593 
whisky  in,  593 

Shoulder,  handkerchief  bandage  of,  303 
spica,  290,  291 
support  of,  by  hand,  288 
Sialagogue,  definition  of,  342 
Sibilant  rales,  225 
Sickness,  green,  color  of  skin  in,  245 
Side  splints,  312 
Side-chains,  428 
Sighing,  212 
Sigmoid  flexure,  155 
Silicon  bandage,  308 
Silk  bougies,  sterilization  of,  486 
sutures,  489 

sterilization  of,  489 
Silkworm-gut,  487 

sterilization  of,  488 
Silver  catheters,  sterilization  of,  481 
cleaning  of,  834 
nitrate  as  antiseptic,  460 
enteroclysis,  169 
in  hemorrhage,  608 
in  lavage  of  stomach,  191 
stick,  460 

mitigated,  460 
wire  sutures,  490 

sterilization,  490 
Sims'  position,  231 

speculum,  236 
Sinapism,  140 
Singultus,  222,  715 
Sinks,  cleaning  of,  835 
Sinus,  657 

packing  of,  512 
Sitz-bath,  hot,  97 
Skimmed  milk,  764 
Skin,  blueness  of,  244 
bronzing  of,  245 
color  of,  244 

in  jaundice,  244,  245 
condition  of,  as  symptom,  220 
induration  of,  247 
observation  of,  244 
pigmented  patches  on,  245 
preparation  of,  for  operation,  473,  474, 

508 

Skin-grafting,  sterilization  in,  477 
Skull,  fracture  of,  of  base,  treatment,  640 
of  vault,  complications  from,  640 

treatment,  639 
treatment,  638 

immediate,  633,  634 
Sleeping  sickness,  tsetse  fly  as  carrier, 

394 

Sleeplessness,  706 
Sling,  foot-,  90 

for  support,  of  arm,  304 
Slough,  80,  657 
Slow  heart,  207 

pulse,  207 
Small  pulse,  205 
Smallpox,  nursing  in,  436 


Smallpox,  rash  in,  728 
confluent,  728 

vaccination  in,  423 
Smear,  blood-,  252 
Smear-culture,  398 
Smoky  urine,  272,  280 
Snake-bite,  672 

poisoning  from,  treatment,  386 
Soap  liniment,  153 

plaster,  153 

poultice,  136 

suppository,  171 
Soapsuds  enema,  161 
Social  state  of  nurse,  36 
Soda,  chlorinated,  as  antiseptic,  462 

in  urine,  271 
Soda-water,  779 
Soft  pulse,  205 
Soft-boiled  eggs,  842 
Solutions,  measuring,  469 

mixing  of,  from  crude  drug,  470 

sterilization  of,  496 
Somnifacient,  definition  of,  342 
Sonorous  rales,  225 
Soporific,  definition  of,  342 
Sordes,  74 
Sore,  cold,  731 
Sounds,  adventitious,  224 

friction-,  224,  225 

uterine,  237 
Southey's  tubes,  530 
Spanish  windlass,  606 
Special  chart,  218 
Specific  gravity  of  urine,  271,  277 
Speculum,  Sims',  236 
Sphincter  ani,  155 
Sphygmograms,  209 
Sphygmograph,  209 
Sphygmomanometer,  204 
Spica,  290 

of  groin,  291 

of  instep,  291 

of  shoulder,  290,  291 

of  thumb,  292 

pelvic,  291 
Spice  poultice,  142 
Spinal  jacket,  Sayre's,  306 

meningitis,  convulsions  in,  683 

puncture,  524.    See  also  Lumbar  punc- 
ture. 

Spindle-shape  bacillus,  392 
Spine,  fracture  of,  treatment,  643 

immediate,  634 
Spiral  bandage,  reversed,  289 
of  lower  extremity,  289 
of  upper  extremity,  289 
simple,  289 
Spirilla,  390,  391,  392,  393 

comma  of,  393 
Spirit,  proof,  459 
Spirits,  dosage  of,  346 
Spirits  of  mindererus,  349 

proof,  459 

Spirochetse,  390,  393 
Splint,  308 

angular,  312 
anterior,  313 
internal,  312 

back,  311 

Bond's,  314  , 

box-,  312 

Dupuytren's,  316 

hip,  Thomas',  315 


INDEX 


875 


Splint,  Hqdgen's,  316 

immobilization  in  use  of,  311 

in  fractures,  635 

knee,  Thomas',  315 

Levis,  314 

long,  311 

padding  of,  308 

preparation  for  application,  309 

pressure-sore  from,  30!) 

rules  in  applying,  310 

side,  312 

straight,  310 

Thomas'  hip,  315 

knee,  315 

Splinting,  Gooch's  coaptation,  318 
Sponge,  cold,  113 

receptacle  in  operating-room,  544 
Sponges,  counting  of,  in  operations,  553 

sea-,  499 

sterilization  of,  499 
Spontaneous  hemorrhage,  595,  612 
Spore  of  bacilli,  392,  393 
Spots,  Koplik's,  729 

typhoid,  729 
Sprain,  645,  647 

adhesive  strapping  in,  326 

ice  compresses  in,  124 

treatment,  648 
Spread,  63 
Sputum,  260 

as  source  of  infection,  262 

bloody,  261 

examination  of,  263 
microscopic,  263 

false  coloring  of,  262 

fetid,  262 

gangrenous,  262 

in  tuberculosis,  262 

infectious,  262 

microscopic  examination,  263 

mucoid,  260 

mucopurulent,  260 

nummular,  262 

profuse,  260 

prune-juice,  261 

purulent,  261 

pus  in,  261 

red-currant  jelly,  261 

rusty,  261,  262 

scanty,  260 

watery,  261 
Sputum-cups,  262 
Squamous  eczema,  733 
Square  knot,  328 
Stadium,  723 

of  fever,  199 
Staining  bacteria,  398 

precautions,  399 
Stains,  acid,  for  bacteria,  399 

basic,  for  bacteria,  399 

bichlorid   of    mercury,    on    linen,    re- 
moval, 821 

blood,  on  linen,  removal,  820 

on  scrubbed  wood,  removal,  833 

coffee,  on  linen,  removal,  821 

fecal,  on  linen,  removal,  820 

fruit,  on  linen,  removal,  821 

Gabbett's,  for  tubercle  bacillus,  400 

grease,  on  linen,  removal,  821 
on  scrubbed  wood,  removal,  833 

ink,  on  linen,  removal,  820 

on  scrubbed  wood,  removal,  833 

iodin,  on  linen,  removal,  821 


Stains,    iodin,    on   scrubbed  wood,   re- 
moval, 833 

iron-rust,  on  linen,  removal,  821 
oil,  on  linen,  removal,  821 
on  scrubbed  wood,  removal,  833 
tea,  on  linen,  removal,  821 
Standing  position,  234 
Stands  in  operating-room,  543 
Staphylococcus,  390,  391,  392 
epidermidis  albus,  439 
pyogenes  albus,  439 
aureus,  439 

wound  infection  by,  656 
citreus,  439 
Starch,  animal,  741 
as  infant  food,  774 
bandage,  307 
bath,  105 

effect  of  cooking  on,  760 
enema,   166 
poultice,  136 
Starchy  beverages,  781 
Starvation,  700 
Status  epilepticus,  682 
Steam,  inhalation  of,  365 
sterilization  by,  449 
sterilizer,  449 

improvised,  450 
Steapsin,  752,  753 
Stearin,  742 
Stegomyia,  transmission  of  yellow  fever 

by,  394 

Stercoraceous  vomitus,  258 
Sterile  nurse,  502 

(No.  1),  duties  of,  503 
in  operating-room,  549 
Sterilization,  447 

Arnold  sterilizer  for,  449 
autoclave  for,  450,  451 
by  actual  flame,  448 
by  baking,  448 
by  boiling,  448 
by  dry  heat,  448 
by  heat,  447 
by  moist  heat,  449 
by  steam,  449 
chemical,  454 
fractional,  453 
in  cauterization,  477 
in  dirty  and  infected  wounds,  477 
in  operations  on  abdomen,  474 
on  brain,  475 
on  breast,  474 
on  cervix,  475 
on  ear,  476 
on  eyes,  476 
on  glands  of  axilla,  475 

of  neck,  475 
on  kidney,  474 
on  limbs,  475 
on  mouth,  476 
on  nose,  476 
on  palate,  476 
on  rectum,  475 
on  stomach,  474 
on  tongue,  476 
on  vagina,  475 
in  skin-grafting,  477 
in  surgical  work,  471 
in  wet-cupping,  477 
of  air-pump,  482 
of  cannulas,  481 
of  catgut,  490 


876 


INDEX 


Sterilization  of  china,  487 
of  dressings,  496,  509 
of  dusting-powders,  495 
of  enamelware,  487 
of  field  of  operation,  473 
of  filiform  catheters,  486 
of  gauze,  499 
of  glass,  487 

catheters,  486 
of  glycerin,  496 
of  hand-brushes,  500 
of  hands,  471,  507 

Fiirbringer's  method,  472 
Kelly's  method,  472 
Schatz  method,  472 
Stimson's  method,  473 
Weir's  method,  473 
of  hollow  needles,  480 
of  horsehair  sutures,  489 
of  hypodermic  needle,  480 
of  instruments,  478 

in  operations  in  private  houses,  561 
of  iodoform  gauze,  498 

powder,  496 

of  kangaroo  tendon  sutures,  495 
of  ligatures,  487 
of  mackintoshes,  487 
of  metal  catheters,  486 
of  milk,  772,  840 
of  nail-cleaners,  500 
of  needles,  479 
of  oils,  496 
of  ointments,  496 
of  Paquelin  cautery,  481 
of  plain  catgut,  492 
of  rectal  tubes,  485 
of  rubber,  483 
bougies,  486 
catheters,  485 
gloves,  484 
sheets,  487 
tissue,  485 
of  sea-sponges,  499 
of  sharp  instruments,  479 
of  silk  bougies,  486 

sutures,  489 
of  silkworm-gut,  488 
of  silver  catheters,  481 

wire  sutures,  490 
of  skin,  508 
of  solutions,  496 
of  sutures,  487 
of  syringes,  482 
of  trocars,  481 
steps,  452 
Sterilizer,  Arnold,  449 

in  operations  in  patient's  home,  558 
steam,  449 

improvised,  450 
Sterilizing  hopper,  468 
Sternocleidomastoid  muscles,  action  of, 

in  respiration,  214 
Stertorous  respiration,  212 
Stiff  bandage,  304 
Stimson's    method    of    sterilization    of 

hands,  473 
Stimulating  bath,  105 

enema,  163 
Stings,  672 

Stitches,  removal  of,  514 
Stock-books,  ward,  816 
Stomach,  absorptive  activity,  determin- 
ing, 259 


Stomach,  baby's,  capacity  of,  774 
contents,  anacidity  of,  259 
hyperacidity  of,  259 
subacidity  of,  259 
dilatation  of,  diet  in,  798 
diseases  of,  diet  in,  792 
examination  of,  258 

test-meals,  258 
hemorrhage  from,  616 
lavage  of,  188 
first  step,  189 
in  poisoning,  370 
in  vomiting  after  operations,  574 
second  step,  190 
third  step,  191 

motor  activity,  determination,  259 
operations  on,  sterilization  in,  474 
perforation  of,  624 
peristalsis  in,  754 
rash,  732 

Stomachics,  time  of  administering,  345 
Stomach-tube,  feeding  by,  192 
Stomatitis,  condition  of  tongue  in,  221 
Stools,  264.     See  also  Feres. 
Stramonium,    poisoning   by,   treatment, 

385 
Strapping,  323 

adhesive,    323.         See    also    Adhesive 

strapping. 
Straw  mattress,  60 
Strawberry  tongue,  728 
Streptococcus,  390,  391,  392 
pyogenes,  440 

infection  by,  symptoms,  441 
Stretcher,  carrying  patient  on,  89 
Strict  bacteria,  389 
Stridulent  respiration,  212 
Strychnin  in  hemorrhage,  611 
in  shock,  593 

overdose  of,  treatment,  385 
poisoning,  convulsions  in,  683 

treatment,  384 
sulphate    in    shock    after    abdominal 

section,  581 
Stump,  bandage  of,  293 

recurrent,  293 

handkerchief  bandage  of,  303 
Stupe,  137 
alkaline,  139 
as  a  counterirritant,  138 
belladonna  and  glycerin,  139 
digitalis,  139 
ice,  125 
medicated,  139 
method  of  making,  138 
poppy-head,  139 
sedative,  138 
turpentine,  138 

in    intestinal    distention    after    ab- 
dominal section,  579 
in  tympanites  after  abdominal  sec- 
tion, 580 
i  Stye,  674 
Styptic  collodion  in  hemorrhage,  608 

cotton  in  hemorrhage,  608 
Styptics  in  hemorrhage,  608 
Subacidjty,  gastric,  259 
Subclavian  artery,  compression  of,  601 
Subcutaneous  infusion  of  salt  solution, 

514 

Subjective  symptoms,  219,  220 
Subluxation,  645 
Subsultus,  222 


INDEX 


877 


Succus  entericus,  753 

Sucroses,  741 

Sudamen,  722 

Sudorific,  definition  of,  342 

Sugar,  741 

cane-,  effect  of  cooking  on,  761 

fruit-,  742 

grape-,  742 

in  urine,  282.     See  also  Giycosuria. 

invert,  742 
Sulphate  of  copper  as  antiseptic,  400 

of  zinc  as  emetic  in  poisoning,  371 
Sulphur  bath,  105 

disinfection  of  room,  465 
Sulphuric  acid  in  urine,  271 

poisoning  by,  373 
Sunstroke,  698 
Suppository,  171 

glycerin  jelly,  171 

ice,  171 

soap, 171 

rectal,  171 

urethra!,  171 

vaginal,  171 

Suppuration,  121,  247,  441 
Surgeon's  knot,  328 
Surgical  bacteriology,  439 

bed,  changing  of,  66,  67 

procedures,  minor,  522 

technic,  501 

principles  of,  501 

work,  preparation  in,  471 

sterilization  in,  471 
Sutures,  487 

removal  of,  514 

sterilization  of,  487 
Sweat-bath,  108 

pilocarpin  in  conjunction  with,  109 
Sweating,  720 

induction  of,  by  hot  bath,  95 

treatment  of,  721 

unilateral,  722 
Sweeping  floors,  ward,  828 
Swelling  as  symptom,  220 

brawny,  247 

of  inflammation,  120 
Sylvester's  method  of  artificial  respira- 
tion, 691 
Symptoms,  219 

objective,  219,  220 

subjective,  219,  220 
Syncope,  696 

treatment  of,  697 
Syphilis,  blebs  in,  730 

gummatous  nodules  in,  730 

infection  by,  416,  419 

mercury  in,  433 

moist  papules  in,  730 

mucous  patches  in,  730 

potassium  iodid  in,  433 

rash  in,  730  £ 

tubercles  in,  730 
Syringe,  balj,  157 

hypodermic,  357 

sterilization  of,  482 
Syringing  ear,  178 
Syrup,  dosage  of,  346 

Fellow's,  349 
Systole,  202 


TABLE,  anesthetist's,  541 
emergency,  542 


Table  for   operations  in  private  house, 

560 

operating-,  538.      See  also  Operating- 
table. 

preparation,  in  operating-room,  543 
reserve,  in  operating-room,  542 
Tablespoon,    apothecaries'    equivalent, 

334 

Tachycardia,  207 
Tallquist's      method      for      estimating 

hemoglobin,  254 
Tampon,  180 
kite-tail,  181 
vaginal,  180 
Tank  bath,  98 
Tannic  acid  enteroclysis,  168 
in  epistaxis,  619 
in  hemorrhage,  608 
Tapeworms,  395 

in  feces,  268 
Tapping,  528 
Tarry  stools,  266,  267 

after  enterorrhagia,  615 
Tartar  emetic,  350 
T-bandage,  297 
Tea,  780 
beef-,  845 
chicken-,  845 
flaxseed-,  846 
ginger-,  846 
linseed-,  846 
meat-,  844 

stains  on  linen,  removal,  821 
Teaching  nurse,  methods  of,  23 
Teaspoon,  apothecaries'  equivalent,  334 
Technic,  surgical,  501.    See  also  Surgical 

technic. 
Teeth,  condition  of,  as  symptom,  221 

injury  to,  from  drugs,  352 
Temperature,   194 
as  symptom,  221 
chart,  216 

in  intermittent  malaria,  198 
in  typhoid  fever,  198 
of  lobar  pneumonia,  197 
decline  of,  199 

favorable  to  growth  of  bacteria,  390 
lowering  of,  195 
normal,  194 

deviations  from,  194 
of  bath-room,  93 
of  enema,  160 
raising  of,  195 
remissions  of,  in  fever,  724 
rise  of,    as   symtpom   of   sepsis   after 

abdominal  section,  583 
slightly  raised,  194 
subnormal,  194 
taking  of,  201 

by  voiding  urine  over  bulb  of  ther- 
mometer, 201 
in  axilla,  201 
in  mouth,  201 
in  rectum,  201 
ward,  837 
Temporal  artery,  pressure  of,  602 

taking  of  pulse  at,  202 
Tendons,     separation     of,     in     incised 

wounds,  653 

Teniacide,  definition  of,  341 
Tension  of  pulse,  203 
Tent,  croup,  367 
Test,  Bottger's,  for  glycosuria,  282 


878 


INDEX 


Test  copper,  for  glycosuria,  282 

Fehling's,  for  glycosuria,  282 

Fowler's,  for  urea  in  urine,  284 

Heller's,  for  albuminuria,  279 

nitric  acid,  for  albuminuria,  279 

Trommer's,  for  glycosuria,  282 

Wjdal,  401 

in  typhoid  fever,  254,  401 
Test-meals,  258 

Boas',  258 

Ewald's,  258 

Riegel's,  258 

Tetanic  convulsions,  677,  678 
Tetanus  antitoxin,  425,  443 

bacillus  in  surgery,  442 
spore  formation  in,  394 

convulsions  in,  678,  683 

from  gunshot  wound,  655 

from  punctured  wound,  654 

from  wounds,  661 

infection  by,  416,  418 
Tetany,  convulsions  in,  678,  684 
Tetracocci  (tetrads),  390,  391,  392 
Tetrads  (tetracocci),  390,  391,  392 
Tetragenococci,  390 
Thermic  fever,  698 
Thermometer,  care  of,  201 

Centigrade,  200 

converting  to  Fahrenheit  scale,  200 

clinical,  200 

Fahrenheit,  200 

converting  to  Centigrade  scale,  200 

Rdaumur,  200 
Thermostat,  131 
Thiersch's  solution,  463 
Thirst  after  hemorrhage,  treatment,  611 

after  operations,  575 
Thomas'  hip  splint,  315 

knee  splint,  315 

Thoma-Zeiss  hemocytometer,  249 
Thoracic  breathing,  213 
Thready  pulse,  205 
Three-cornered  bandage  for  arm,  302 
Thrill,  223,  224 
Throat,  bacteria  in,  413 

burns  of,  treatment,  665 

condition  of,  as  symptom,  221 

examination  of,  242 

foreign  bodies  in,  removal  of,  687 

hemorrhage  from,  620 

inhalations  for,  367 
Thrombosis,  659 
Thrombus,  659 

Thrush,  condition  of  tongue  in,  221 
Thumb,  spica  of,  292 
Tidal  respiration,  213 
Tjnctures,  dosage  of,  346 
Tinea  circinata,  734 

favosa,  735 

sycosis,  734 

tonsurans,  734 

tricophytina,  734 

Tissue,  rubber,  sterilization  of,  485 
Toast-water,  846 
Tolerance  to  drugs,  344 
Tongue,     condition     of,     as    symptom, 

221 

in  scarlet  fever,  221 
in  stomatitis,  221 
in  thrush,  221 

operations  on,  sterilization  in,  476 

strawberry,  728 
Tonic  convulsion,  677 


Tonics,  time  of  administering,  346 
Top  sheet,  turning  of,  without  exposing 

patient,  68 

Torsion  in  hemorrhage,  609,  610 
Tortuous  bandage,  292 
Tourniquet,  field,  605 
application  of,  605 

improvised,  606 

in  hemorrhage,  604 
Toxalbumins,  407 
Toxemia,  432 
Toxins,  407,  425,  428 
Toxophore,  428,  429 
Trachea,  foreign  bodies  in,  689 
Tracheal  rales,  225 
Tracheotomy,  586 

position  for,  587 

tube,  587 

in  place,  588 

Training,  essentials  of,  19 
Training-school     attached    to    general 

hospitals,  15 
to  hospitals,  12 
for  children,  12,  14 
for  women,  12,  13 
to  private  hospitals,  17 
to  special  hospitals,  13 

choice  of,  11 

correspondence,  11 

course  of,  44 

domestic  duties  in,  53 

examinations  in,  49 

hours  of  work,  25 

lecturers  in,  45 

length  of  course,  25 

order  of  studies  in,  46 

practical  instruction  in,  49-53 

registration  of,  20 

salaries  paid  by,  26-29 

short-course,  11 

theoretic  instruction  in,  44 
Trance,  706 

Trauma,  648.     See  also  Wounds. 
Traumatic  embolism,  659 

erysipelas,  661 

gangrene,  658 

hemorrhage,  595,  612 

scarlet  fever,  661 
Tray,    preparation,    for    sterilization  of 

skin,  508 
Tremor,  222,  223 
Trendelenburg  position,  233 

in  operation  in  private  house,  560 
Trephining  in  fracture  of  skull,  640 
Triangular  bandage,  301 
Trichiniasis,  396 
Triple  phosphates  in  urine,  276 
Trocars,  sterilization  of,  481 
Trommer's  test  for  glycosuria,  282 
Trypsin,  752,  753 
Tsetse  fly  as  carrier  of  sleeping  sickness, 

394 

Tub-bath,  cold,    100.        See  also   Cold 
bath. 

hot,  92.     See  also  Hot  bath. 

in  bed,  106 

medicated,  105 
Tubercle  bacillus,  393 

Gabbett's  stain  for,  400 
Tubercles,  246 

in  syphilis,  730 
Tuberculin,  425 
Tuberculosis,  diet  in,  802 


INDEX 


879 


Tuberculosis,   infection  by,  416 
nursing  in,  437 
sputum  in,  262 
sweating  in,  treatment,  721 
tuberculin  in,  425 
Tubes,  Southey's,  530 
Tully's  powder,  350 
Tumblerful,    apothecaries'    equivalent, 

334 

Turning  mattress  under  patient,  69 
patient,  87 
top  sheet  without  exposing  patient, 

68 

Turpentine  bath,  106 
enema,  165 
in  intestinal  distention  after  abdoim- 

nal  section,  580 
stupe,  138 

in   intestinal   distention   after    ab- 
dominal section,  579 
in  tympanites  after  abdominal  sec- 
tion, 580 
Tympanites  after  abdominal  section,  580 

as  symptom  of  perforation,  624 
Tympanum,  241 
Typhoid  bacillus,  393 
agglutination,  402 
Widal  reaction  of,  401 
fever,  bacteria  in  feces  in,  269 
Brandt  bath  in,  100 

cyanosis   and   shivering   after, 

103 
hemorrhage     and     perforation 

during,  104 
symptoms  of   injurious  effect, 

102 

diet  in,  789 

Ehrlich's  diazo-reaction  in,  284 
hemorrhage  in,  104 
nursing  in,  433 
perforation  in,  104 
rash  in,  729 

temperature  chart  in,  198 
Widal  reaction  in,  254,  401 
rash,  246 
spots,  729 
Typhus  fever,  rash  in,  729 


ULCER,  duodenal,  diet  in,  794 
gastric,  diet  in,  794 
of  leg,  adhesive  strapping  in,  326 
Ulnar  artery,  compression  of,  at  wrist, 

600 

Undigested  stools,  264 
Union  of  fractures,  629 
bony,  630 
delayed,  631 
fibrous,  631 

Unit,  immunity,  of  antitoxin,  426 
Unsterile  nurse,  502 

(No.  2),  duties  of,  505 
Urates  in  urine,  270,  278 
Urea,  747 
in  urine,  270 

chemical  tests,  284 
Fowler's  test,  284 
quantity,  estimation  of,  284 
Uremia,  747 

convulsions  in,  679 

treatment,  681 
in  pregnancy,  682 
Ureters,  catheterization  of,  238 


Urethral  suppository,  171 
Uric  acid  in  urine,  270 
Urinary  meatus,  184 

tract,  hemorrhage  from,  622 
Urine,  269,  747 

abnormal  substances  in,  272 
albumin  in,  279 

Esbach's   albuminometer   for   esti- 
mating amount,  279 

Heller's  test  for,  279 
alkaline,  272 
ammoniacal,  273 
aromatic  substances  in,  271 
bacterial  casts  in,  276 
bile  in,  283 
blood  casts  in,  276 

in,  276,  280 
blood-red,  272 
boiling,  278 

calcium  oxalate  in,  diet  for,  801 
calculus  in,  271 
casts  in,  275 

chemical  examination,  276 
chlorin  in,  271 
chyle  in,  282 
clearness  of,  273 
cloudy,  277 
color  of,  272 
composition  of,  270 
creatinin  in,  271 
crystals  in,  276 
density  of,  271 

dextrose  in,  282.     See  also  Glycosuria. 
epithelial  casts  in,  276 
examination  of,  274 

before  operation,  565 

chemical,  276 

microscopic,  275,  276 
fatty  casts  in,  276 
granular  casts  in,  276 
grape-sugar  in,  282.      See  also  Glyco- 
suria. 

gravel  in,  283 
hippuric  acid  in,  271 
hyaline  casts  in,  275 
incontinence  of,  222 
indican  in,  283 
lithia  in,  271 
magnesia  in,  271 

microscopic  examination,  275,  276 
milky,  273,  282 
mucus  in,  281 
odor  of,  273 
oily  casts  in,  276 
orange-red,  272 
organic  matter  in,  271 
phosphates  in,  278 
phosphoric  acid  in,  271 
pigments  in,  271 
pink,  273 
potash  in,  271 
pus  casts  in,  276 

in,  276,  281 
quantity  voided,  273 
reaction  of,  272,  277 
salts  in,  271 
smoky,  272,  280 
soda  in,  271 
solids  in,  270 

specific  gravity  of,  271,  277 
sugar  in,  282.     See  also  Glycosuria. 
sulphuric  acid  in,  271 
test  solutions  for,  276 


880 


INDEX 


Urine,  triple  phosphates  in,  276 
urates  in,  270,  278 
urea  in,  270 

chemical  tests,  284 
Fowler's  test,  284 
quantity,  estimation  of,  284 
uric  acid  in,  270 
waxy  casts  in,  275 
Urticaria,  732 
Uterine  sound,  237 
Uterus,  douching  of,  174 


VACCINATION,  423,  424 

technic,  424 

Vagina,  operations  on,  sterilization  in, 
475 

packing  of,  181 
Vaginal  applicators,  237 

douche,  172 

bichlorid  of  mercury,  174 

boric  acid,  174 

position  of  patient  in,  173 

examination,  235 

suppository,  171 

tampon,  180 
Varicella,  rash  in,  727 
Vaselin  in  burns,  666 
Vegetables,  cooking  of,  761 

diet  of,  785 

Vegetative  reproduction  of  bacteria,  393 
Velpeau's  bandage,  296 
Venesection,  521 
Venous  hemorrhage,  594 
Ventilation,  ward,  837 
Veratrum   viride,   poisoning  by,   treat- 
ment, 386 
Verbal  reports,  814 
Vertical  extension,  321 
Vesical  rales,  225 
Vesicant,  definition  of,  342 
Vesicants,  140,  149 
Vesicle,  246 
Vesicular  eruption,  246 

Capules,  246 
rios,  393 

Vinegar  in  hemorrhage,  608 
Virus,  attenuated,  inoculation  with,  424 
Visiting  rounds  of  head  nurse,  838 
Visitors  after  abdominal  section,  579 

ward,  826 
Vital  knot,  210 
Volatile  drugs,  action  of,  344 
Volume  of  pulse,  205 
Vomiting,  222,  712 
after  operations,  572 

bismuth  subnitrate  in,  573 

bromids  in,  575 
cerium  oxalate  after,  575 
cocain  hydrochlorid  in,  575 
hypodermoclysis  in,  575 
lavage  of  stomach  for,  574 
salt  solution  in,  S75 
bilious,  257 
causes  of,  712 
central,  713 
character  of,  256 
forcible,  257 
in  pregnancy,  714 
profuse,  256 
projectile,  257 
reflex,  713 
treatment  of,  713 


Vomitus,  256 

blood  in,  257 
altered,  257 
fresh,  257 

coffee-ground,  257 

consistence  of,  257 

fecal,  258 

mucus  in,  257 

pus  in,  258 

stercoraceous,  258 
Von  Fleischl's  hemoglobinometer,  253 


WALLS  of  ward,  cleaning,  835 
Ward  management,  805 
blankets,  822 
care  of  linen,  820 

of  porcelain,  832 
charts,  815 
cleaning  bedding,  836 

beds,  836 

brass,  834 

copper,  834 

enamel  ironware,  831 

glass,  831 

hopper,  835 

ice-chest,  835 

kitchen  crockery,  834 

marble,  831 

metals,  834 

nickel,  834 

pewter,  834 

saucepans,  834 

silver,  834 

sinks,  835 

walls,  835 
diet-sheets,  815 
division  of  labor,  806 
doctor's  orders,  report  of,  814 
domestic  work,  827 
dusting,  830 

and  cleaning,  807 
hours  off  duty,  811 
inventories,  816 
laundry  books,  818 
mopping  floors,  828 
night  nurse,  808 

report,  814 
orderly,  809 
patient's  effects,  823 

visitors,  826 
polished  furniture,  832 
polishing  floors,  829 
pulse,  report  of,  814 
report  book,  814 
reporting,  812 
respirations,  report  of,  814 
scrubbing  floors,  828 
stock-books,  816 
sweeping  floors,  828 
temperature,  837 

report  of,  814 
ventilation,  837 
verbal  reports,  814 
visitors,  826 
ward-maid,  809 
medicine  chest,  352 
Ward-maid,  809 
Wash,  black,  350 
mouth-,  76 
red,  350 
yellow,  350 
Wash-stands  in  operating-room,  544 


INDEX 


881 


Washing  bed-pan,  83 

hair,  84 

patient  without  exposure,  71 
Water,  739,  740 

amount  of,  to  be  added  to  solution, 
method  of  finding,  470 

as  food,  778 

carbonated,  779 

cold,  in  hemorrhage,  608 

glass  bandage,  308 

hot,  in  hemorrhage,  607 

mineral,  779 

proper  care  of,  in  prevention  of  infec- 
tion, 417,  418 
Water-bed,  82 

method  of  placing  patient  on,  82 
Water-borne  diseases,  414 

prophylaxis,  417 
Water-hammer  pulse,  208 
Water-supply  of  operating-room,  544 
Watery  sputum,  261 

stools,  265 
Wax  bandage,  308 
Waxy  casts  in  urine,  275 
Weights  and  measures,  330 

metric,  334 
Weir's  method  of  sterilization  of  hands, 

473 

Wet  pack,  117 
Wet-cupping,  144 

sterilization  in,  477 
Wheals,  246 
Wheat-meal,  776 
Wheatmeal  poultice,  135 
Wheezing,  212 
Whey,  764,  841 

white  wine,  768,  841 
Whisky  enema,   164 

in  shock,  593 
White  asphyxia  of  newborn,  696 

corpuscles,  250 

wine  whey,  768,  841 
Whitewash  as  antiseptic,  461 
Whitlow,  675 

Whooping-cough,  nursing  in,  437 
Widal  reaction,  254,  401 
Wild  delirium,  703 
Windlass,  Spanish,  606 
Wine  and  egg-albumen,  843 

measure,  331 

of  antimony,  350 

of  ipecacuanha  as  emetic  in  poisoning, 
371 

whey,  white,  841 

Wineglass,  apothecaries'  equivalent,  334 
Wire  sutures  of  silver,  490 

sterilization,  490 
Wiry  pulse,  206 
Wood,  scrubbed,  stains  on,  removal,  833 

56 


Wooden  bedsteads,  60 
Worms  in  feces,  268 
Wounds,  648 

accidental,  cleansing  of,  651 

shock  in,  650 

treatment  of,  650 
adhesive  strapping  of,  327 
complications  of,  655 
contused,  treatment  of,  654 
dirty  and  infected,  sterilization  in,  477 
embolism  complicating,  659 
erysipelas  from,  660 
gunshot,  655 
*         tetanus  from,  655 
healing  of,  649 

by  first  intention,  649 

by  granulation,  649,  650 

by  secondary  intention,  649 

primary,  649 
incised,  648 

drainage  of,  653 

separation  of  tendons  in,  653 

treatment  of,  652 
infection  in,  440,  656 

from  bacillus  pyocyaneus,  656 

from       staphylococcus       pyogenes 
aureus,  656 

mixed,  442 

with  pus-producing  organisms,  419 
inflammation  in,  655 
keloid  complicating,  659 
lacerated,  649 

treatment  of,  654 
punctured,  649 

tetanus  from,  654 

treatment  of,  654 
repair  of,  652 

scarlet  fever  infection  from,  661 
septicemia  from,  060 
sloughing  of,  657 
tetanus  from,  661 
Wright's  theory  of  immunity,  429 


YAWNING,  212 

Y-bandage,  301,  302 

Yeasts,  388 

Yellow  fever,  prophylaxis,  420 

transmission  of,  by  mosquitos,  394 
wash,  350 

Young's  rule  of  dosage,  342 
Y-shaped  binder,  301,  302 


ZIEHL'S  carbol-furhsin  solution,  400 
Zinc  sulphate  as  emetic  in  poisoning,  371 
Zociglea,  392 
Zymogenic  bacteria,  390 


Books  for  Nurses 


PUBLISHED   BY 


W.    B.   SAUNDERS   COMPANY 

West  Washington  Square  Philadelphia 

London:    9,  Henrietta  Street,  Covent  Garden 


Sanders'   Nursing 


A  NEW  WORK 


Miss  Sanders'  new  book  is  undoubtedly  the  most 
complete  and  most  practical  work  on  nursing  ever 
published.  Everything  about  every  subject  with 
which  the  nurse  should  be  familiar  is  detailed  in 
a  clean  cut,  definite  way.  There  is  no  other 
nursing  book  so  full  of  good,  practical  informa- 
tion— information  }^ou  need. 

Modern  Methods  in  Nursing.  By  GEORGIANA  J.  SANDERS, 
formerly  Superintendent  of  Nurses  at  Massachusetts  Gen- 
eral Hospital.  i2mo  of  881  pages,  with  227  illustrations. 

Cloth,  $2.50  net. 

Aikens'  Home  Nurse's  Handbook 

PRACTICAL 

The  point  about  this  work  is  this:  It  tells  you, 
and  shows  you  just  how  to  do  those  little — but 
none  the  less  important — things  entirely  omitted 
from  other  nursing  books,  or  at  best  only  inci- 
dentally treated.  The  chapters  on  "Home  Treat- 
ments" and  "Every-Day  Care  of  the  Baby," 
stand  out  as  particularly  practical.  Then  the 
"Points  to  be  Remembered" — terse,  crisp  re- 
minders— is  a  feature  of  great  value. 

Home  Nurse's  Handbook.  By  CHARLOTTE  A.  AIKENS, 
formerly  Director  of  the  Sibley  Memorial  Hospital,  Wash- 
ington, D.C.  i2mo  of  276  pages,  illustrated.  Cloth,  $1.50  net 


Stoney's  Nursing 


NEW   (4th)  EDITION 


Of  this  work  the  American  Journal  of  Nursing  says:  "It  is  the 
fullest  and  most  complete  and  may  well  be  recommended  as 
being  of  great  general  usefulness.  The  best  chapter  is  the  one 
on  observation  of  symptoms  which  is  very  thorough."  There 
are  directions  how  to  improvise  everything. 

Practical  Points  in  Nursing.  By  EMILY  M.  A.  STONEY,  formerly  Super- 
intendent of  the  Training  School  for  Nurses  in  the  Carney  Hospital, 
South  Boston,  Mass.  12010,495  pages,  illustrated.  Cloth.  $1.75  net 

Stoney's  Materia  Medica       NEw  04  EDITION 

Stoney's  Materia  Medica  was  written  by  a  head  nurse  who 
knows  just  what  the  nurse  needs.  American  Medicine  says 
it  contains  "all  the  information  in  regards  to  drugs  that  a 
nurse  should  possess." 

Materia  Medica  for  Nurses.  By  EMILY  M.  A.  STONEY,  formerly  Super- 
intendent of  the  Training  School  for  Nurses  in  the  Carney  Hospital, 
South  Boston.  Mass.  i2mo  volume  of  300  pages.  Cloth,  $1.50  net. 


NEW  (3d)  EDITION 


Stoney's  Surgical  Technic 

The  first  part  of  the  book  is  devoted  to  Bacteriology  and 
Antiseptics;  the  second  part  to  Surgical  Technic,  Signs  of 
Death,  Bandaging,  Care  of  Infants,  etc. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  EMILY  M.  A. 
STONEY.  Revised  by  FREDERIC  R.  GRIFFITH,  M.  D.,  New  York, 
izmo  volume  of  311  pages,  fully  illustrated.  Cloth,  $1.50  net 

Goodnow's  First-Year  Nursing  ILLUSTRATED 

Miss  Goodnow's  work  deals  entirely  with  the  practical  side  of 
first-year  nursing  work.  It  is  the  application  of  text-book 
knowledge.  It  tells  the  nurse  how  to  do  those  things  she  is  called 
upon  to  do  in  her  first  year  in  the  training  school — the  actual 
ward  work. 

First-Year  Nursing.  By  MINNIE  GOODNOW,  R.  N.,  formerly  Super- 
intendent of  the  Women's  Hospital,  Denver.  xanoof  328  pages, 
illustrated.  Cloth,  $1.50  net. 


Aikens'  Hospital  Management 

This  is  just  the  work  for  hospital  superintendents,  training- 
school  principals,  physicians,  and  all  who  are  actively  inter- 
ested in  hospital  administration.  The  Medical  Record  says: 
"Tells  in  concise  form  exactly  what  a  hospital  should  do 
and  how  it  should  be  run,  from  the  scrubwoman  up  to  its 
financing." 

Hospital  Management.  Arranged  and  edited  by  CHARLOTTE  A. 
AIKENS,  formerly  Director  of  Sibley  Memorial  Hospital,  Washing- 
ton, D.  C.  larno  of  488  pages,  illustrated.  Cloth,  $3.00  net 

Aikens'  Primary  Studies         NEw  (2d)  EDITION 

Trained  Nurse  and  Hospital  Review  says:  "It  is  safe  to  say 
that  any  pupil  who  has  mastered  even  the  major  portion  of 
this  work  would  be  one  of  the  best  prepared  first  year  pupils 
who  ever  stood  for  examination." 

Primary  Studies  for  Nurses.  By  CHARLOTTE  A.  AIKENS,  formerly 
Director  of  Sibley  Memorial  Hospital,  Washington,  D.  C.  izmo  of 
437  pages,  illustrated.  Cloth,  $1.75  net 

Aikens'  Training-School  Methods  and 
the  Head  Nurse 

This  work  not  only  tells  how  to  teach,  but  also  what  should 
be  taught  the  nurse  and  how  muck.  The  Medical  Record  says: 
•'  This  book  is  original,  breezy  and  healthy." 

Hospital  Training-School  Methods  and  the  Head  Nurse.  By  CHAR- 
LOTTE A.  AIKENS,  formerly  Director  of  Sibley  Memorial  Hospital, 
Washington,  D.  C.  izmc  of  267  pages.  Cloth,  $1.50  net 

Aikens'    Clinical    Studies       NEW  (2d)  EDITION 

This  work  for  second  and  third  year  students  is  written  on  the 
same  lines  as  the  author's  successful  work  for  primary  stu- 
dents. Dietetic  and  Hygienic  Gazette  says  there  "  is  a  large 
amount  of  practical  information  in  this  book." 

Clinical  Studies  for  Nurses.  By  CHARLOTTE  A.  AIKENS,  formerly 
Director  of  Sibley  Memorial  Hospital,  Washington,  D.  C.  iamo  of 
569  pages,  illustrated  Cloth,  $2.00  net 


Bolduan  and  Grund's  Bacteriology 

The  authors  have  laid  particular  emphasis  on  the  immediate 
application  of  bacteriology  to  the  art  of  nursing.  It  is  an 
applied  bacteriology  in  the  truest  sense.  A  study  of  all  the 
ordinary  modes  of  transmission  of  infection  are  included. 

Applied  Bacteriology  for  Nurses.  By  CHARLES  F.  BOLDUAN,  M. D., 
Assistant  to  the  General  Medical  Officer,  and  MARIE  GRUND,  M.D., 
Bacteriologist,  Research  Laboratory,  Department  of  Health,  City  of 
New  York.  i2mo  of  166  pages,  illustrated.  Cloth,  $1.25  net. 


Fiske's  The  Body 


A  NEW  IDEA 


Trained  Nurse  and  Hospital  Review  says  "it  is  concise,  well- 
written  and  well  illustrated,  and  should  meet  with  favor  in 
schools  for  nurses  and  with  the  graduate  nurse." 

Structure  and  Functions  of  the  Body.     By  ANNETTE  FISKE.  A.  M., 

Graduate  of  the  Walthatn    Training   School    for    Nurses,    Massa- 
chusetts.   i2mo  of  221  pages,  illustrated.  Cloth,  $1.25  net 


Beck's  Reference  Handbook 


NEW  (3d)   EDITION 


This  book  contains  alt  the  information  that  a  nurse  requires 
to  carry  out  any  directions  given  by  the  physician.  The 
Montreal  Medical  Journal says  it  is  "cleverly  systematized  and 
shows  close  observation  of  the  sickroom  and  hospital  regime." 

A  Reference  Handbook  for  Nurses.  By  AMANDA  K.  BECK.  Grad* 
uate  of  the  Illinois  Training  School  for  Nurses,  Chicago,  111 
jaino  volume  of  244  pages.  Bound  in  flexible  leather,  $1.25  net. 

Roberts'  Bacteriology  &  Pathology 

This  new  work  is  practical  in  the  strictest  sense.  Written 
specially  for  nurses,  it  confines  itself  to  information  that  the 
nurse  should  know.  All  unessential  matter  is  excluded.  The 
style  is  concise  and  to  the  point,  yet  clear  and  plain.  The  text 
is  illustrated  throughout. 

Bacteriology  and  Pathofogy  for  Nurses.  By  JAY  G.  ROBERTS,  Ph.  G., 
M.  D.,  Oskaloosa,  Iowa.  i2mo  of  206  pages,  illustrated.  $1.25  net. 


DeLee's  Obstetrics  for  Nurses 

Dr.  DeLee's  book  really  considers  two  subjects — obstetrics 
for  nurses  and  actual  obstetric  nursing.  Trained  Nurse  and 
Hospital  Review  says  the  "book  abounds  with  practical 
suggestions,  and  they  are  given  with  such  clearness  that 
they  cannot  fail  to  leave  their  impress." 

Obstetrics  for  Nurses.  By  JOSEPH  B.  DEL.EE,  M.  D.,  Professor  of 
Obstetrics  at  the  Northwestern  University  Medical  School,  Chicago. 
i2ino  volume  of  508  pages,  fully  illustrated.  Cloth,  $2.50  net. 


Davis'  Obstetric  &  Gynecologic  Nursing 

NEW  (4th)  EDITION 

The  Trained  Nurse  and  Hospital  Review  says:  "  This  is  one 
of  the  most  practical  and  useful  books  ever  presented  to  the 
nursing  profession."  The  text  is  illustrated. 

Obstetric  and  Gynecologic  Nursing.  By  EDWARD  P.  DAVIS,  M.  D., 
Professor  of  Obstetrics  in  the  Jefferson  Medical  College,  Philadel- 
phia, i-^mo  volume  of  480  pages,  illustrated.  Buckram,  $1.75  net. 

Macfarlane's  Gynecology  for  Nurses 

NEW  (2d)   EDITION 

Dr.  A.  M.  Seabrook,  Woman's  Hospital  of  Philadelphia,  says: 
"It  is  a  most  admirable  little  book,  covering  in  a  concise  but 
attractive  way  the  subject  from  the  nurse's  standpoint." 

A  Reference  Handbook  of  Gynecology  for  Nurses.  By  CATHARINE 
MACFARLANE,  M.  D.,  Gynecologist  to  the  Woman's  Hospital  of  Phila- 
delphia. 321110  of  156  pages,  with  70  illustrations.  Flexible  leather, 
$1.25  net. 

Asher's  Chemistry  and  Toxicology 

Dr.  Asher's  one  aim  was  to  emphasize  throughout  his  book 
the  application  of  chemical  and  toxicologic  knowledge  in  the 
study  and  practice  of  nursing.  He  has  admirably  succeeded. 

i2mo  of  iqo  pages.  By  PHILIP  ASHER,  PH.  G.,  M.  D.,  Dean  and  Pro- 
fessor of  Chemistry,  New  Orleans  College  of  Pharmacy.  Cloth, 
$1.25  net. 


Bohm  &  Painter's  Massage 

The  methods  described  are  those  employed  in  Hoffa's  Clinic 
— methods  that  give  results.  Every  step  is  illustrated,  showing 
you  the  exact  direction  of  the  strokings.  The  pictures  are 
large. 

Octavo  of  gi  pages,  with  97  illustrations.  By  MAX  BOHM,  M.  D., 
Berlin.  Germany.  Edited  by  CHARLES  F.  PAINTER,  M.  D.,  Professor 
of  Orthopedic  Surgery,  Tufts  College  Medical  School,  Boston. 

Cloth,  $1.75  net. 

Eye,  Ear,  Nose,  and  Throat  Nursing 

Medical  Record  says:  "Every  side  of  the  question  has  been 
fully  taken  into  consideration." 

Nursing  in  Diseases  of  the  Eye,  Ear,  Nose  and  Throat.  By  the 
Committee  on  Nurses  of  the  Manhattan  Eye,  Ear  and  Throat  Hospital. 
iamo  of  260  pages,  illustrated.  Cloth,  $1.50  net. 

Friedenwald  and  Ruhrah's  Dietetics  for 

IN  lirSCS  NEW  (3d)  EDITION 

This  work  has  been  prepared  to  meet  the  needs  of  the  nurse, 
both  in  training  school  and  after  graduation.  American  Jour- 
nal of  Nursing  says  it  "is  exactly  the  book  for  which  nurses 
and  others  have  long  and  vainly  sought. ' ' 

Dietetics  for  Nurses.  By  JULIUS  FRIEDBNWALD,  M.  D.,  Professor 
of  Diseases  of  the  Stomach,  and  JOHN  RUHRAH,  M.  D.,  Professor  of 
Diseases  of  Children,  College  of  Physicians  and  Surgeons,  Baltimore. 
i2tno  volume  of  431  pages.  Cloth.  $1.50  net 

Friedenwald  &  Ruhrah  on  Diet        S£% 

Diet  in  Health  and  Disease.  By  Juuus  FRTEDEN- 
WALD,  M.D.,  and  JOHN  RUHRAH,  M.D.  Octavo  vol- 
ume of  857  pages.  Cloth,  $4.00  net. 

Galbraith's   Personal  Hygiene  and  Physical 

Training  for   Women  ILLUSTRATED 

Personal  Hygiene  and  Physical  Training  for  Women.  By  ANNA  M. 
GALBRAITH,  M.  D.,  Fellow  New  York  Academy  of  Medicine.  i2mo 
of  371  pages,  illustrated.  Cloth,  $a.oo  net 

Galbraith's  Four  Epochs  of  Woman's  Life 

THE  NEW  (2d)  EDITION 

The  Four  Epochs  of  Woman's  Life.  By  ANNA  M.  GALBRAITH.  M.D. 
With  an  Introductory  Note  by  JOHN  H.  MUSSER,  M.  D..  University 
of  Pennsylvania,  umo  of  247  pages.  Cloth,  $1.50  net 


McCombs'  Diseases  of  Children  for  Nurses 

NEW  (2d)  EDITION 

Dr.  McCombs'  experience  in  lecturing  to  nurses  has  enabled 
him  to  emphasize/fttf  those  points  thai  nurses  most  need  to  know. 
National  Hospital  Record  says:  "We  have  needed  a  good 
book  on  children's  diseases  and  this  volume  admirably  fills 
the  want."  The  nurse's  side  has  been  written  by  head 
nurses,  very  valuable  being  the  work  of  Miss  Jennie  Manly. 

Diseases  of  Children  for  Nurses.  By  ROBERT  S.  McCOMBS,  M.  D., 
Instructor  of  Nurses  at  the  Children's  Hospital  of  Philadelphia,  izmo 
of  470  pages,  illustrated.  Cloth,  $2.00  net 


NEW  (2d)   EDITION 


Wilson's  Obstetric  Nursing 

In  Dr.  Wilson's  work  the  entire  subject  is  covered  from  the 
beginning  of  pregnancy,  its  course,  signs,  labor,  its  actual 
accomplishment,  the  puerperium  and  care  of  the  infant. 
American  Journal  of  Obstetrics  says:  "  Every  page  empasizes 
the  nurse's  relation  to  the  case." 

A  Reference  Handbook  of  Obstetric  Nursing.  By  W.  REYNOLDS 
WfLSON,  M.D.,  Visiting  Physician  to  the  Philadelphia  Lying  in  Char- 
ily. 3>mo  of  jiS  pages,  illustrated.  Flexible  leather,  $1.25  net 


EDITION 


American  Pocket  Dictionary 

The  Trained  Nurse  and  Hospital  Review  says:  "We  have 
had  many  occasions  to  refer  to  this  dictionary,  and  in  every 
instance  we  have  found  the  desired  information." 

American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  NEWMAN 
DORLAND,  A.  M.,  M.  D.,  Loyola  University,  Chicago.  Flexible 
leather,  gold  edges,  $1.00  net;  with  patent  thumb  index,  $1.25  net 


THIRD 
EDITION 


Lewis'  Anatomy  and  Physiology 

Nurses  Joarnal of  Pacific  Coast  says  "it  is  not  in  any  sense 
rudimentary,  but  comprehensive  in  its  treatment  of  the  sub- 
jects." The  low  price  makes  this  book  particularly  attractive. 

Anatomy  and  Physiology  for  Nurses.  By  LERov  LEWIS,  M.D.,  Lec- 
turer on  Anatomy  and  Physiology  for  Nurses,  Lewis  Hospital,  Bay 
City,  Mich.  12010  of  326  pages,  150  illustrations.  Cloth,  $1.7?  net 


Boyd's  State  Registration  for  Nurses 

JUST  OUT  State  Registration  for  Nurses.  By  LOUIE  CROFT  BOYD,  R.  N.,  Grad- 

2d  EDITION          uate  Colorado  Training  School  for  Nurses.  Cloth,  $1.25  net. 

Paul's  Materia  Medica  NEW  ^  EDITION 

A  Text-Book  of  Materia  Medica  for  Nurses.  By  GEORGE  P.  PAUL,  M.D., 
Samaritan  Hospital,  Troy,  N.  Y.  i2mo  of  282  pages.  Cloth,  $1.50  net. 

Paul's  Fever  Nursing  NEW  (2d)  EDITION 

Nursing  in  the  Acute  Infectious  Fevers.  By  GEORGE  P.  PAUL,  M.D. 
i2mo  of  246  pages,  illustrated.  Cloth,  $1.00  net. 

Hoxie  &  Laptad's  Medicine  for  Nurses 

NEW  (2d)   EDITION,  REWRITTEN 

Medicine  for  Nurses  and  Housemothers.  By  GEORGE  HOWARD 
HOXIE,  M.D.,  University  of  Kansas;  and  PEARL  L.  LAPTAD.  i2mo 
of  351  pages,  illustrated.  Cloth,  $1.50  net. 


Grafstrom's  Mechano-therapy 

Mechano-therapy  (Massage  and  Medical  Gymnastics).       By  AXEL  V, 
GRAFSTROM,  B.Sc.   M.D.,     12010,  200  pages.  Cloth,  $1.25  net. 

Nancrede's  Anatomy 


NEW  (7th)    EDITION 


Esseniials  of  Anatomy.  CHARLES  B.  G.  DENANCREDE,  M.D.,  Univers- 
ity of  Michigan.  i2tno,  400  pages,  180  illustrations.  Cloth,  $1.00  net 

Morrow's  Immediate  Care  of  Injured 

Immediate  Care  of  the  Injured.  By  ALBERT  S.  MORROW,  M.D.,  New 
York  City  Home  for  Aged  and  Infirm.  Octavo  of  354  pages,  with 
242  illustrations.  Cloth,  $2.50  net.  New  (2d)  Edition 

Register's  Fever  Nursing 

A  Text  Book  on  Practical  Fever  Nu-sing.  By  EDWARD  C.  REGISTER, 
M.D.,  North  Carolina  Medical  College.  Octavo  of  350  pages,  illus- 
trated. Cloth,  $2.=;o  net. 

Pyle's  Personal  Hygiene 


NEW  (5th)   EDITION 

A  Manual  of  Personal  Hygiene.    Edited  by  WALTER  L.  PYLE,  M.D. 

Wills   Eye  Hospital,  Philadelphia.    i2mo,  515  pages,  illus.    $1.50  net. 


NEW    (7th)  EDITION 


Morris'  Materia  Medica 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription  Writing. 
By  HENRY  MORRIS,  M.D.  Revised  by  W.  A.  BASTEDO,  M.D.,  Colum- 
bia University,  N.  Y.  i2mo  of  300  pages,  illustrated.  Cloth,  $1.00  net. 

Griffith's  Care  of  the  Baby     NEW  <5th>  EDITION 

The  Care  of  the  Baby.  By  J.  P.  CROZER  GRIFFITH,  M.D.,  Univers- 
ity of  Pennsylvania.  i2mo  of  455  pages,  illustrated.  Cloth,  $1.50  net. 


This  book  is  DUE  on  the  last  date  stamped  below 


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